


MMMM 



MINOR 



AISTD 



OPERATIVE SURGERY 



INCLUDING 



BANDAGING 



BY 

HENRY R. WHARTON, M.D., 

M 

LOFESSOR OF CLINICAL SURGERY IN THE Woman's MEDICAL COLLEGE OF PENN- 
SYLVANIA; SURGEON TO Tin: PRESBYTERIAN HOSPITAL, AND THE CHIL- 
DREN'S HOSPITAL; CONSULTING SURGEON I" ST. CHRISTOPHER'S 
HOSPITAL, THE BRYN MAWR HOSPITAL, AND GIRARD COLLEGE; 
FELLOW OF TUT. AMERICAN SURGICAL ASSOCIATION. 



SIXTH EDITION, ENLARGED AND THOROUGHLY REVISED, 
WITH 532 ILLUSTRATIONS. 




LEA BROTHERS & CO., 
PHILADELPHIA AND NEW YORK. 

1905. 



LIBRARY of CONGRESS 
Two Copies Received 

DEC 5 1905 

Cooy right Entry 
CLASS a. XXc. N». 






^ 






0' 



Entered according to Act of Congress, in the year 1905, by 

LEA BROTHERS & CO., 

In the Office of the Librarian of Congress. All rights reserved. 



WESTCOTT & THOMSON, 
ELECTROTYPERS, PHILADA. 



YILLIAM J. DORNAN. 
PRINTER, PHILADA. 



PREFACE TO THE SIXTH EDITION. 



Ix successive editions the author has been led to add 
operations which are somewhat beyond the vague line 
separating minor from major surgery. Thus the book has 
been broadened beyond its original title in response to a 
liberal interpretation of the wants of its readers. The 
amount of space which it has been possible to allot to 
Operative Surgery renders necessary the selection aud 
concise description of those operative procedures which, 
in the author's judgment, will prove most useful to the 
student. The great attention now paid in medical 
schools to operations on the cadaver, and the importance 
of this method of instruction, have led the author to 
include those procedures which can be advantageously 
practised upon the dead subject, such as Ligation of 
Arteries, Amputations, Excisions of Joints, Operations 
upon Nerves and Tendons. Intestinal Anatomosis, etc. 
Another point in the selection has been the inclusion 
of a number of operations which are frequently required 
in practice, such as Tracheotomy, Intubation of the 
Larynx, the Operations for Appendicitis, Strangulated 
Hernia, etc. 

That a comprehensive manual, covering all but what 
might be termed capital surgery, answers an actual need 
is to be inferred from the call for a sixth edition. It now 
seems appropriate to recognize the greater scope of the 
book by broadening the title. All the features which have 

3 



4 PREFACE TO THE SIXTH EDITION. 

met with favor are retained, including a concise description 
of the various bandages, surgical dressings, and minor 
surgical procedures employed at the present day. The 
subject of Bandaging is fully illustrated with photographs 
clearly showing their application. The preparation and 
use of aseptic and antiseptic dressings have also received 
full consideration, and the importance of Surgical Bac- 
teriology is recognized in a special chapter. The subject 
of Fractures and Dislocations is also photographically 
illustrated. The whole volume, in fact, has been liberally 
treated from the pictorial standpoint. 

The author has construed the favor bestowed on this 
work as an incentive for keeping it thoroughly revised to 
the date of each issue. Surgery progresses, and those books 
are fortunate which meet with a demand enabling their 
authors by frequent revision to keep them abreast of its 
continuous advances. It is hoped that the broadened 
scope of its new edition will render the volume more 
serviceable to the student and practitioner. 

The author desires to express his thanks to Dr. Francis 
Olcott Allen, Jr., for assistance in revising the proof-sheets. 

H. B. W. 

1725 Spruce St., Philadelphia. 
November, 1905. 



CONTENTS. 



PART I. 

BANDAGING. 

PAGES 

Varieties of Bandages 23-42 

Bandages of the Head and Neck 42-55 

Bandages of the Upper Extremity 55-70 

Bandages of the Trunk 70-74 

Bandages of the Lower Extremity 74-86 

Special Bandages 87-98 

Fixed Dressings or Hardening Bandages 98-114 



PART II. 

MINOR SURGERY. 

Surgical Dressings 114-120 

Minor Surgical Procedures 120 177 

Ron tgen Rays or /-rays 177 ls-_> 

kinesthetics 182-207 

Trusses for Hernia . 207-210 

Catheters and Bougies 210-220 

Sutures and Ligatures 22<>-2:;s 

Treatment of Hemorrhage 238-257 

Abscess 259-2(12 

Shock 262-265 

Wounds, Burns and Scalds, Sprains 265-281 



PART III. 

ASEPSIS AND ANTISEPSIS. 

Surgical Bacteriology 281-294 

Theory of Asepsis and Antisepsis in Wound Treatment . . 294-299 

Agents Employed to Secure Asepsis 299-308 

5 



b CONTENTS. 

PAGES 

Preparation of Materials Used in Aseptic Operations .... 308-320 
Methods and Dressings Employed to Secure Asepsis in Wounds 320-339 



PAKT IV. 

FRACTURES. 

General Considerations of Fractures 339-351 

Separation of Epiphyses 351-354 

Treatment of Special Fractures 354-410 

Compound and Ununited Fractures 410-417 

PART V. 

DISLOCATIONS. 

General Considerations of Dislocations 417-418 

Special Dislocations 418-447 

Old Dislocations, Compound Dislocations 447-449 



PART VI. 

OPERATIONS. 

Ligation of Arteries 451-453 

Ligation of Special Arteries 453-480 

PART VII. 

AMPUTATIONS. 

General Considerations of Amputations 481-494 

Special Amputations 494-534 

PART VIII. 

EXCISIONS AND RESECTIONS AND SPECIAL OPERATIONS. 

General Considerations of Excisions and Resections .... 537-542 

Special Excisions and Resections 542-555 

Osteotomy . 555-557 



CONTENTS. 7 

PAGES 

Trephining the Skull 557-560 

Laminectomy . 561 

Operations upon Nerves 562-567 

Operations upon Tendons 567-573 

Excision of the Breast 573-575 

Tracheotomy 575-582 

Intubation of Larynx 582-588 

Operations upon the Kidney 588-589 

Operations upon the Ureter 589-591 

Operations upon the Colon 591-593 

Operations for Appendicitis 593-597 

Lithotomy 597-598 

Circumcision 599 

Excision of the Testicle 600 

Operation for Varicocele 600 

Operation for Hydrocele 600-601 

Operations upon the Gall-bladder 601-603 

(Esophagotomy 603-604 

Operations upon the Stomach 604-612 

Operations upon the Intestines 612-621 

Intestinal Anastomosis 614 

Operation for Strangulated Hernia 621 

Operations for the Radical Cure of Hernia 622-629 



Index 631 



PAET I. 

BANDAGING 



Bandages. — These constitute one of the most widely 
used and important surgical dressings; they are employed 
to hold dressings in contact with the surface of the body, 
to make pressure, to hold splints in place in the treatment 
of fractures and dislocations, and to maintain in their 
natural position parts which may have become displaced. 

Bandages may be prepared of various materials, such 
as linen, crinoline, flannel, gauze or cheese-cloth, rubber- 
sheeting, or muslin, bleached or unbleached ; the lat- 
ter material is the most commonly employed, by reason 
of its cheapness; flannel, from its elasticity, is sometimes 
used, but its employment for bandages is now generally 
limited to its use in dressings for operative work in con- 
nection with the eye and abdomen, and for a primary 
roller in the application of plaster-of- Paris dressings. 

Bandages are either simple, when composed of one piece 
of material, such as the ordinary roller-bandage, or com- 
pound., when prepared of one or more pieces adapted by 
size and shape to particular objects. 

The importance of being familiar with the general 
rules of bandaging and proficient in the application of 
the roller-bandage cannot be overestimated, and both the 
student and the general practitioner will never have cause 
to regret the time occupied in learning to apply neatly 



this form of surgical dressing. 



17 



18 



BANDAGING 



A well-applied bandage adds to the security of the dress- 
ing and the comfort of the patient, and the method of 
application often secures for the physician the confidence 
both of the patient and of his friends ; while, on the 
other hand, a badly applied bandage is apt to be uncom- 
fortable and insecure, and to meet with their adverse 
criticism. 

The Roller-bandage. — The roller-bandage consists of 
a strip of woven material, prepared from some one of the 
materials previously mentioned, of variable length and 
width according to the portion of the body to which it is 

Fig. 1. 




Bandage-winder. 



to be applied ; this, for ease of application, is rolled into 
a cylindrical form. 

The material commonly employed for the roller-band- 
age is unbleached muslin, although, for special purposes, 
linen, flannel, rubber-sheeting, crinoline, gauze or cheese- 
cloth may be used. It is important that the roller- 
bandage should consist of one piece, free from seams and 
selvage, for if made of a number of pieces sewed together, 
or if it contains creases or selvage, it cannot be so neatly 
applied, and it is not so comfortable to the patient, as it is 
apt to leave creases upon the skin. 



THE ROLLER-BANDAGE. 19 

In preparing the ordinary muslin bandage, the material 
is torn in strips varying in length and width according to 
the part of the body to which it is to be applied, and it is 
then rolled into a cylinder, either by the hand or by a 
machine constructed for the purpose (Fig. 1). 

It is important that every student and practitioner 
should be able to roll a bandage by hand, for in practice 
the medical attendant may at any moment be called upon 
to prepare a bandage, in order to apply a dressing, and the 
art of preparing a bandage is easily acquired by a little 

Fig. 2. 




Rolling a bandage by hand. 

practice. To roll a bandage by hand, the strip of muslin 
should be folded at one extremity several times until a 
small cylinder is formed ; this is then grasped by its ex- 
tremities by the thumb and index finger of the left hand ; 
the free extremity of the strip is then grasped between 
the thumb and index finger of the right hand, and by 
alternate pronation and supination of the right hand the 
cylinder is revolved and the roller is formed ; the firm- 
ness of the roller will depend upon the amount of tension 
which is kept upon the free extremity of the strip during 
the revolution of the cylinder (Fig. 2). A bandage rolled 



20 



B AS D AGING. 



in the form of a cylinder is called a single or single-headed 
roller (Fig. 3) ; if rolled from each extremity toward the 
centre, so that two cylinders are formed joined by the 



Fig. 3. 



Fig. 4. 





Single roller. 



Double roller. 



central portion of the strip, the double or double-headed 
roller is formed (Fig. 4). 

Double rollers are not much used, and in practice the 
single roller will be found to be amply sufficient for the 
application of almost all the bandages employed in sur- 
gical dressings. 

The free end of the roller-bandage is called the initial 
extremity ; the end which is enclosed in the centre of the 
cylinder is its terminal extremity ; and the portion between 
the extremities the body ; a roller has also two surfaces, 
external and internal. 

Dimensions of Bandages. — Bandages vary in length 
and width according to the purposes for which they are 
employed, and in practice it will be found that a small 
variety of bandages will be amply sufficient for the appli- 
cation of the ordinary surgical dressings. 

The following list, comprising those most frequently 
used, will show their dimensions : 

Bandages one inch wide, three yards in length, for band- 
ages for the hand, fingers, and toes. 



GENERAL RULES FOR BANDAGING. 21 

Bandages two inches wide, six yards in length, for head- 
bandages and for the extremities in children. 

Bandages two and a half inches wide, seven yards in 
length, for bandages of the extremities in adults ; a roller 
of this size is the one most generally used. 

Bandages three inches wide, nine yards in length, for 
bandages of the thigh, groin, and trunk. 

Bandages four inches wide, ten yards in length, for 
bandages of the trunk. 

General Rules for Bandaging. — In applying a roller- 
bandage, the operator should place the external surface of 
the free extremity of the roller upon the part, holding it 
in position with the fingers of the left hand until fixed by 
a few turns of the roller, the cylinder being held in the 
right hand by the thumb and fingers ; for thus as the 
bandage is unwound it rolls into the operator's hand, 
thereby giving him more control of it ; care should also 
be taken that the turns are applied smoothly to the surface, 
and that the pressure exerted by each turn is uniform. 

When a bandage is applied to a limb, the surgeon should 
see that the part is in the position it is to occupy as re- 
gards flexion and extension when the dressing is com- 
pleted, for a bandage applied when the limb is flexed will 
exert too much pressure when the limb is extended, and 
then may, by the pressure it exerts, become a matter of 
discomfort or even of danger to the patient, or if applied 
to an extended limb it will become uncomfortable upon 
flexion. 

My experience has been that, as a rule, those who have 
had little experience with the application of the roller- 
bandage are apt to apply the bandages too tightly, and 
this may lead to disastrous consequences, gangrene of the 
extremities having resulted from the too tight application 
of bandages, especially in the dressing of fractures. Pro- 
fessor Ashhurst, in his clinical teaching, advised students 
to make use of a larger number of turns of a bandage in 
securing fracture-dressings rather than to depend upon a 
few turns too firmly applied — advice which certainly con- 
duces to the safety and comfort of the patient. When the 



22 



BANDAGING. 



bandage has been completed, the terminal extremity should 
be secured by a pin or safety-pin applied transversely 
to the bandage, and if a pin be used its point should be 



Fig. 5. 




Method of removing a bandage. 



buried in the folds of the bandage ; if the bandage be a 
narrow one, the end may be split and the two tails result- 
ing secured around the part by tying. 



Fig. 6. 




Bandage-scissors. 



Removal of Bandages. — In removing a bandage, the 
folds should be carefully gathered up in a loose mass as 



VARIETIES OF BANDAGES. 



23 



the bandage is unwound, the mass being transferred rapidly 
from one hand to the other, thus facilitating its removal 
and preventing the part from becoming entangled in its 
loops (Fig. 5). If it is desirable to cut the bandage to 
remove it, the use of scissors made for this purpose will 
be found most satisfactory (Fig. 6). 



VARIETIES OF BANDAGES. 

Circular Bandage. — This bandage consists of a few 
circular turns around a part, each turn covering accurately 
the preceding turn. This variety of bandage may be used 
to retain a dressing to a limited portion of the head, neck, 
or limbs, to make compression upon the veins of the arm 
before performing venesection, or to secure a compress to 
control venous hemorrhage (Fig. 11). 

Oblique Bandage. — In this form of bandage the turns 
are carried obliquely over the part, leaving uncovered 
spaces between the successive turns (Fig. 7). It cannot 



Fig. 




Oblique bandage 



be applied with much firmness on account of the swelling 
of the uncovered portions of skin between the turns of 
the bandage, and its principal use is for the application of 
temporary dressings, such as wet dressings which may re- 
quire frequent removal. 

Spiral Bandage. — In this bandage the turns are carried 



24 BANDAGING. 

around the part in a spiral direction, each turn overlap- 
ping a portion of the preceding one, usually one-third or 
one-half; it may be applied as an ascending spiral (Fig. 8) 

Fig. 8. 




Ascending spiral bandage. 



or as a descending spiral (Fig. 9). This bandage may 
be used to cover a part which does not increase rapidly in 
diameter ; for instance, the abdomen, chest, or arm. 



Fig. 9. 




Descending spiral bandage. 

Spiral Reversed Bandage. — This bandage is a spiral 
bandage, but differs from the ordinary spiral bandage in 
having its turns folded back or reversed as it ascends a 
part the diameter of which gradually increases. By its 
use, it is possible to cover by spiral turns a part conical in 
shape, so as to make equable pressure upon all parts of 
the surface. The reverses are made as follows : After 



VARIETIES OF BANDAGES. 



25 



fixing the initial extremity of the roller, as the part in- 
creases in diameter the bandage is carried off a little 
obliquely to the axis of the limb for from four to six 
inches ; the index finger or thumb of the disengaged hand 
is placed upon the body of the bandage to keep it securely 
in place upon the limb, the hand holding the roller is 
carried a little toward the limb to slacken the unwound por- 
tion of the bandage, and by changing the position of the 
hand holding the bandage from extreme supination to 
pronation the reverse is made (Fig. 10). Care should be 



Fig. 10. 




Method of making reverses. 

taken not to attempt to make the reverse while the band- 
age is tense, for by so doing the bandage is twisted into 
a cord which is unsightly and uncomfortable to the patient, 
instead of forming a closely fitting reverse. 

The reverse should be completed before the bandage is 
carried around the limb, and when it has been completed 
it may be slightly tightened so as to conform to the part 
accurately. 

The reverses should be in line to have the bandage pre- 
sent a good appearance, and care should be taken that the 



26 



BANDAGING. 



reverses should not be made over prominent bony parts 
of the limb, for if they occupy such positions they cause 
creases in the skin and become uncomfortable to the 
patient. 

To make reverses neatly and to have them in line, 
require skill and practice ; a well-applied spiral reversed 
bandage is a test of a competent bandager. 

Spica-bandage. — When the turns of the roller cross 
each other in the form of the Greek letter lambda, leaving 
the previous turn about one-third uncovered, the bandage 
is known as a spica-bandage (Fig. 12). These spica- 



Fig. 11. 



Fig. 12. 




Circular bandage. 



Spica-bandage. 



bandages are especially serviceable as a means of retaining 
surgical dressings upon particular portions of the surface 
of the body, such as the shoulder, groin, or foot. 

Figure-of-eight Bandage. — This bandage receives its 



COMPOUND BANDAGES. 



27 



name from the turns being applied so as to form a figure- 
of-eight. This method of application is made use of in 
the Barton's bandage, the bandages of the knee and elbow, 
and many other bandages. 



Fig. 13. 




Recurrent bandage. 



Recurrent Bandage. — This bandage derives its name 
from the fact that the roller after covering a certain part 
of the surface is reflected and brought back to the point 
of starting ; it is then reversed and carried toward the 
opposite point, and this manipulation is continued until 
the part is covered by these recurrent turns, which are 
then secured by a few circular turns (Fig. 13). This is 
the bandage usually employed in the dressing of stumps 
after amputation. 

Compound Bandages. 

These bandages are usually formed of several pieces of 
muslin or other material, sewed or pinned together, and 
are employed to fulfil some special indication in the appli- 
cation of dressings to particular parts of the body. The 
most useful of the compound bandages are the T-bandages 
and the many-tailed bandages. 



28 



BANDAGING. 



T-bandage. — The single T-bandage consists of a hori- 
zontal band to which is attached, about its middle, another 
having a vertical direction ; the horizontal piece should be 
about twice the length of the vertical piece (Fig. 14). The 



Fig. 14. 




Single T-bandage. 



single T-bandage may be used to retain dressings to the 
head, the horizontal piece being passed around the head 
from the occiput to the forehead, the vertical piece being 



Fig. 15. 




Single T-bandage for cbest. 



passed over the head and secured to the horizontal piece, 
the shape and width of the two pieces being varied accord- 
ing to the indications. In applying dressings to the anal 



COMPO UND BAND A GES. 



29 



region or perineum, or in securing a catheter in a perineal 
wound, the single T-bandage will be found most useful. 
In applying a T-bandage for this purpose, the body of the 
bandage is placed over the spine, just above the pelvis, and 
the horizontal portion is tied around the abdomen. The 
free extremity is split into two tails for about two-thirds 
of its length, and is carried over the anal region and 
brought up between the thighs, the terminal strips passing 
one on each side of the scrotum and being secured to the 
horizontal strip in front. The single T-bandage may be 

Fig. 16. 




T-bandage of groin. 

variously modified according to the indications which are 
to be met ; for instance, in applying a dressing to the 
breasts the horizontal strip passing around the chest may 
be made ten or twelve inches in width ; the vertical 
strip, two inches in width, passes from the back over the 
shoulder and is secured to the horizontal strip in front 
(Fig. 15), For the groin, a piece of muslin six inches 



30 



BANDAGING. 



wide at its base and thirty inches long is sewed to a hori- 
zontal strip of muslin one and a half yards long and two 
inches in width. It may be applied as in Fig. 16 to hold 
a dressing to this part. 

Double T-bandage. — The double T-bandage differs 
from the single bandage in having two vertical strips 
attached to the horizontal strip, and it may be used for 
much the same purposes as the single T-bandage (Fig. 17). 



Fig. 17. 




Double T-bandage. 



It may be conveniently used for retaining dressings to the 
chest, breast, or abdomen ; when used for this purpose the 
horizontal portion should be from eight to twelve inches 
wide and long enough to pass one and a quarter times 
about the chest-; two vertical strips, two inches wide and 
twenty inches long, should be attached to the horizontal 
strip a short distance apart near its middle. In applying 
this bandage to the chest, the horizontal strip is placed 
around the chest so that the vertical strips occupy a posi- 
tion on either side of the spine ; the overlapping end of 
the horizontal portion is secured by pins or safety-pins, 
and the vertical strips are next carried one over either 
shoulder and secured to the other portion of the bandage 
in front of the chest (Fig. 18). 

The double T-bandage may also be used to secure dress- 



COMPOUND BANDAGES. 



31 



ings to the nose, in which event the strips should be quite 
narrow, about one inch in width, and should be applied as 
shown in Fig. 19. 



Fig. 18. 



Fig. 19. 





Double T-bandage of chest. 



Double T-bandage of nose. 



Many -tailed Bandages or Slings. — These bandages 
are prepared from pieces of muslin of various lengths and 
breadths, which are split at each extremity into two, three, 
or more tails up to within a few inches of their centres, 
their width and length being regulated by the part of the 
body to which they are to be applied. 

The, four-tailed bandage may be found useful as a tem- 
porary dressing in cases of fracture of the jaw, or to hold 
dressings to the chin. It may be prepared by taking a 
portion of a roller-bandage three inches wide and one 
yard in length, and splitting each extremity up to within 
two inches of the centre; it is then applied as seen in 
Fig. 20. 

The four-tailed bandage may also be used to retain dress- 
ings to the scalp, and may be prepared by taking a piece of 
muslin one yard and a quarter long and six or eight inches 
in width, splitting it at each extremity into two tails within 
six inches of the centre ; it may then be applied as seen 
in Fig. 21. 

The four- tailed bandage may also be used in the tern- 



32 



BANDAGING. 



porary dressing of fractures of the clavicle, the body of 
the bandage being placed upon the elbow of the injured 



Fig. 20. 



Fig. 21. 





Four-tailed bandage of chin. 



Four-tailed bandage of head. 



side, two tails passing around the body, fixing the arm to 
the side, and two tails passing over the sound shoulder. 



Fig. 22. 




Many-tailed bandage of abdomen. 



Many-tailed Bandage of Abdomen. — This bandage may 
also be used for holding dressings in contact with the abdo- 
men or trunk, and is the bandage which most surgeons 



HANDKERCHIEF-BAXDA GES. 



33 



employ to hold the dressings to a laparotomy wound, and 
to give support to the abdominal walls after this oper- 
ation. In preparing this bandage, a strip of muslin or 
flannel, one and a half yards in length and eighteen to 
twenty inches in width, is required ; the extremities may 
be split on each side to within six inches of the centre 
so as to form a four- or six-tailed bandage. In applying 
this bandage to the abdomen, the body is placed upon the 
patient's back and the tails are brought around the abdo- 
men and overlap each other, and when sufficiently firmly 
drawn to make the desired amount of pressure they are 
secured by means of safety-pins (Fig. 22). 

Handkerchief-bandages. 

The use of handkerchiefs or square pieces of muslin 
for the temporary or permanent dressing of wounds, fract- 
ures, or dislocations was advocated many years ago by M. 
Mayor, a Swiss surgeon, who wrote an extensive work 



Fig. 23. 



Fig. 24. 



I J J I 



fe 



1 



Ste? 1 






■ % : iii 



The square. 



The oblong. 



upon this subject, in which he reduced their application to 
a system. He employed a handkerchief or a square piece 
of muslin, and by various modifications in the application 
of these developed a number of very ingenious bandages. 
The various forms which the handkerchief or square 
(Fig. 23) is made to assume are as follows : The oblong, 



34 



BANDAGING. 



made by folding the square once or twice on itself (Fig. 
24). The triangle, made by bringing together the diag- 
onal angles of the square (Fig. 25). The line of the fold- 
ing is known as the base, the angle opposite the base the 
apex, and the other angles the extremities. 



Fig. 25 




The triangle. 



The cravat is prepared from the triangle by bringing the 
apex to its base, and folding it a number of times upon 
itself until the desired width is obtained (Fig. 26). 



Fig. 26. 



The cravat. 



The cord is formed from the cravat twisted upon itself 
(Fig. 27). The names of the various handkerchief-band- 
ages are derived from the shape of the handkerchiefs 
used and the parts to which they are applied ; the names 



Fig. 27. 



The cord. 



serve as guides in their application. It is to be remem- 
bered that the base of the triangle or the body of the cravat 
is to be placed upon the portion, the designation of which 
forms the first portion of the name of the bandage ; thus, 



HA NDKER CHIEF-BASDA GES. 



35 



in the occipito- frontal triangle, the shape of the handker- 
chief is given, and we know that the base of the triangle 
is to be applied to the occiput and the apex carried to the 
forehead. In using the cravats the same rule applies ; 
thus, in the bis-axillary cravat the body of the cravat is 
to be placed in the axilla of the affected side, the extremi- 
ties crossed over the corresponding shoulder and carried 
over the chest, one before, the other behind, to the axilla 
of the opposite side, where they are secured. 




Fig. 29. 




Occipitofrontal triangle. 



Mento-vertico-occipital cravat. 



The Occipito-frontal Triangle. — To apply this hand- 
kerchief, place the base of the triangle upon or a little 
below the occiput, and bring the apex forward over the 
head, allowing it to drop over the forehead ; next bring 
the extremities of the handkerchief forward and tie them 
in a knot over the forehead ; finally turn up the apex over 
the knotted ends and pin it to the bodv of the handker- 
chief (Fig. 28). 

The Mento-vertico-occipital Cravat. — To apply this 
handkerchief, the middle of the base of the cravat is placed 
under the chin ; the extremities are then carried in front 



36 



BANDAGING. 



of the ear on each side to the vertex of the skull, and are 
crossed at that point ; the ends are then carried downward 
over the parietal region to the occiput, and are secured by 
a knot at this point (Fig. 29). Another method of apply- 
ing this handkerchief consists in placing the base of the 



Fig. 30. 




Mento-vertico-occipital cravat (modified). 

cravat under the chin and carrying the extremities over 
the vertex of the skull, crossing them at that point ; then 
carrying them downward to the occiput, and crossing them 
again here and passing them forward around the chin, and 
finally securing the ends by a knot (Fig. 30). The turns 
of the latter handkerchief correspond exactly to the turns 
of the Barton's bandage of the head. 

These handkerchief-bandages may be used to secure 
dressings to the chin or scalp, or may be employed as tem- 
porary dressings to secure fixation of the parts in cases of 
fracture or dislocation of the jaw. 

The Bis-axillary Cravat. — To apply this handker- 
chief, the body of the cravat is placed in the axilla, and 
the ends are brought up, one in front of, the other behind, 
the axilla, and are made to cross over the top of the 



HANDKERCHIEF-BANDA GES. 



37 



shoulder ; the extremities are then carried across the back 
and chest respectively to the opposite axilla, where they 
are secured by tying (Fig. 31). This handkerchief may 
be employed to secure dressings in the axilla, or to hold 
dressings in contact with the shoulder. 



Fig. 31. 




Bis-axillary cravat. 

The Dorso-axillary Cravat. — This handkerchief is 
applied by placing the body of the cravat over the spine 
between the scapulae, and then carrying one extremity over 
the shoulder and through the axilla backward to meet the 
other extremity, which has been carried through the axilla 
and over the other shoulder to the back, where the ends 
are secured by a knot (Fig. 32). This handkerchief may 
be used to hold dressings to the axilla or upper portion of 
the back of the chest, 

The Compound Dorso-bis-axillary Cravat. — To ap- 
ply this handkerchief, two cravats are required. The base 
of one cravat is placed over the front of one shoulder, and 



38 



BANDAGING. 



the ends are passed, one over the top of the shoulder, the 
other through the axilla, and they are then secured by a 
single knot over the scapula ; the ends are next secured by 
tying them in a loop. The second cravat is next placed 
in front of the shoulder on the opposite side, and the ends 



Fig. 32. 




Dorsoaxillary cravat. 

are respectively carried over the shoulder and through the 
axilla to the back, where they are secured by a single knot ; 
the ends of the handkerchief are then passed through the 
loop of the first handkerchief and secured by a knot 
(Fig. 33). This handkerchief may be used to draw the 
shoulders backward in cases of dislocation or fracture of 
the clavicle. 

Triangular Cap or Suspensory of the Breast. — To 
apply this handkerchief, the base of the triangle is placed 
under the affected breast, and one extremity is carried be- 
neath the axilla of the same side, and the other extremity 
is carried around the opposite side of the neck, and they 



HANDKERCHIEF-BANDA GES. 



39 



are secured together upon the back by a knot; the apex 
should then be brought up over the breast and shoulder 
of the affected side, and pinned to the bandage over the 
scapula (Fig. 34). This handkerchief may be employed 
to sling the breast in nursing- women, or to hold a dressing 
to the breast. 

Fig. 33. 




/fe> 



Compound dorso-bis-axillary cravat. 

The Gluteo-femoral Triangle. — In applying this hand- 
kerchief, a cravat is first fastened around the waist, and a 
second handkerchief folded into a triangle has its base 
placed in the gluteo-femoral fold, and its extremities car- 
ried around the thigh and secured in front by a knot; 
the apex of the handkerchief is then carried upward and 
passed beneath the cravat around the waist, and is turned 
down and pinned to the body of the triangle (Fig. 35). 
This handkerchief may be used to retain dressings to the 
region of the buttock or hip; by unpinning the apex and 
turning it downward, ready access can be had to the parts 
beneath. 



40 BANDAGING. 

Gluteo-inguinal Cravat. — In applying this handker- 
chief, the base of the cravat is placed just over the gluteo- 
femoral fold, and the extremities are carried forward, one 

Fig. 34. 




Triangular cap or suspensory of the breast. 

around the inner, the other around the outer portion of 
the thigh, and they are made to cross in the groin ; the 
ends are next passed around the pelvis and secured to- 
gether upon the back by a knot (Fig. 36). This handker- 
chief may be employed to hold dressings to the region of 
the groin. 

By employing two cravats, a double gluteo-inguinal 
cravat may be applied, which may be used to hold dress- 
ings to both groins. The turns of these cravats corre- 
spond to the turns of the single and double spica-band- 
ages of the groin. 

I have described a few of the many ingenious bandages 



HANDKERCHIEF-BANDAGES. 



41 



devised by Mayor to substitute the use of the roller- 
bandage, which will give the student some idea of their 



Fig. 35. 




Gluteo-femoral triangle. 



Fig. 36. 




Gluteo-inguinal cravat. 



design and application. It is well to bear in mind this 
system of dressing, for the occasion might occur in which 



42 BANDAGING. 

the ordinary means of bandaging could not be obtained, 
and the use of handkerchiefs might answer a useful pur- 
pose as temporary dressings. I think their principal use 
is for temporary dressings, and I do not believe they will 
ever take the place of the roller-bandage, which can be 
applied with greater nicety and exactness, and certainly 
presents a much neater appearance. 



BANDAGES OF THE HEAD. 

Barton's Bandage. Roller Two Inches in Width, Six 
Yards in Length. — The initial extremity of the roller 
should be placed on the head just behind the mastoid 
process, and the bandage should then be carried under the 
occipital protuberance obliquely upward under and in front 
of the parietal eminence across the vertex of the skull, 
then downward over the zygomatic arch, under the chin, 
thence upward over the opposite zygomatic arch and over 
the top of the head, crossing the first turn which was made, 
as nearly as possible in the median line of the skull, and 
carrying the turns of the roller under the parietal eminence 
to the point of commencement. The bandage is then 
passed obliquely around under the occipital protuberance 
and forward under the ear to the front of the chin, thence 
back to the point from which the roller started. These 
figure-of-eight turns over the head and the circular turns 
from the occiput to the chin should be repeated, each turn 
exactly overlapping the preceding one until the bandage 
is exhausted (Fig. 37). The extremity should then be 
secured by a pin ; and pins should be introduced at the 
points where the turns cross each other, to give additional 
fixation to the bandage. In applying the bandage, care 
should be taken to see that the turns overlap each other 
exactly, and that the turns passing over the vertex cross 
as nearly as possible in the median line of the skull 
(Fig. 38). 

Modified Barton's Bandage. — To obtain additional 
security in the application of the Barton's bandage, a turn 



BANDAGES OF THE HEAD. 



43 



of the bandage passing from the occiput to the forehead 
may be made, this turn being interposed between the turns 
of the bandage as ordinarily applied (Fig. 39). In ap- 
plying this bandage, after the first set of turns has. been 
completed — that is, after the bandage has been brought 
back to the occiput — the bandage is carried forward upon 
the head just over the ear, around the forehead and back- 
ward above the ear on the opposite side to the occiput ; 
this being done, the ordinary figure-of-eight and circular 



Fig. 37. 



Fig. 38. 





Burton's bandage. 



Barton's bandage, showing crossing of turxus 
at vertex. 



turns are made, and when these have been completed 
another occipi to-frontal turn may be made as described 
above, and this may be repeated as often as is desired 
until the bandage is exhausted, when the extremity is fast- 
ened with a pin, and pins are introduced also at all points 
at which the turns cross. 

Use. — This bandage is one of the most useful of the 



44 



BANDAGING. 



bandages of the head, being employed to secure fixation 
of the jaw in cases of fracture or dislocation, and for the 
application of dressings to the chin. I have also employed 
it in place of the head-gear in slinging patients for the 
application of the plaster-of- Paris jacket in cases of dis- 
ease of the spine, a stout cord or a piece of bandage about 
three inches wide and one yard long being passed under 
the turns crossing over the vertex ; this cord is then se- 
cured to the cross-bar of the extension apparatus (Fig. 40). 
This will be found quite as comfortable to the patient as 



Fig. 39. 



* ■ 






s^sikij^ 




4 



/ 



Modified Barton's bandage. 



the ordinary head-gear employed, and much less likely to 
slip out of place and interfere with the breathing of the 
patient. 

A firmly applied Barton's bandage holds the jaws so 
closely together that care should be taken in applying it 
to patients who are under the influence of an anaesthetic, 



BANDAGES OF TEE HEAD. 



45 



for if vomiting occurs the material may not escape from 
the mouth, and suffocation might occur unless the bandage 
were promptly removed. This accident I once saw occur, 
and the patient's condition was alarming until the bandage 
was cut, allowing the jaw to be opened and the contents 
of the mouth to escape. 

Gibson's Bandage. Boiler Two Inches in Width, Six 
Yards in Length. — The initial extremity of the roller 
should be placed upon the 
vertex of the skull in a line 
with the anterior portion of 
the ear; the bandage is then 
carried downward in front of 
the ear to the chin, and passed 
under the chin, and is carried 
upward on the same line until 
it reaches the point of starting. 
The turns are repeated until 
three complete turns have been 
made ; the bandage is then con- 
tinued until it reaches a point 
just above the ear, when it is 
reversed and is carried back- 
ward around the occiput, and 
is continued around the head 
and forehead until it reaches 
its point of origin ; these cir- 
cular turns are applied until 
three have been made. When 
the bandage reaches the occi- 
put, having completed the third 
turn, it is allowed to drop down 
to the base of the skull, and it is then carried forward 
below the ear and around the chin, being brought back 
upon the opposite side of the head and neck to the point 
of origin ; these turns are repeated until three complete 
turns have been made, and upon the completion of the 
third turn the bandage is reversed and carried forward 
over the occiput and vertex to the forehead, and its 



Fig. 40. 




• 






xmnm 


\) 


A 





Barton's head-bandage, employed 
for suspension. 



46 BANDAGING. 

extremity is here secured with a pin. Pins should also 
be applied at the points where the turns of the bandage 
cross each other (Fig. 41). 

Use. — This bandage may be used to fix the lower jaw in 
cases of fracture or dislocation of the jaw, but is very apt 
to change its position, and is, therefore, not so satisfactory 
as the Barton's bandage for this purpose. 



Fig 




Gibson's bandage. 

Oblique Bandage of the Angle of the Jaw. Roller 
Two Inches in Width, Six Yards in Length. — The initial 
extremity of the roller is placed just in front of and above 
the left ear, and if the left angle of the lower jaw is to be 
covered in, the bandage is then carried from left to right, 
making two complete turns around the cranium from the 
occiput to the forehead ; if, however, the right angle of 
the lower jaw is to be covered in, the turns should be made 
in the opposite direction. Having made two turns from 
the occiput to the forehead, the bandage is allowed to drop 
down upon the neck, and is carried forward under the ear 
and under the chin to the angle of the jaw ; it is next 
carried upward close to the edge of the orbit, and obliquely 
over the vertex of the skull, then down behind the right 
ear, continuing this oblique turn under the chin to the left 



BANDAGES OF THE HEAD. 



47 



Fig. 42. 



angle of the jaw, where it ascends in the same direction as 
the previous turn. Three or four of these oblique turns 
are made, each turn overlapping the preceding one and 
passing from the edge of the orbit toward the ear until 
the space is covered in ; the bandage is then carried to a 
point just above the ear on the opposite side, is reversed, 
and finished with one or two circular turns from the occi- 
put to the forehead, the extrem- 
itv being secured by a pin (Fig. 
42). 

Use. — This will be found one 
of the most useful of the head- 
bandages ; it may be used with 
a compress in treating fractures 
of the angle of the lower jaw, 
for holding dressings to the 
lower part of the chin and to 
the vault of the cranium, and 
is especially useful in retaining 
dressings to the sides of the 
face and the parotid region . A s 
before stated, it may be applied 
to cover either the right or left 
side of the face, and, by reason 
of the oblique turns, holds its 
position most securely, having little tendency to become 
displaced. 

Recurrent Bandage of the Head. Boiler Two Inches 
in Width, Six Yards in Lenc/th. — The initial extremity of 
the roller is placed upon the lower part of the forehead 
and the bandage is carried twice around the head from the 
forehead to the occiput to secure it. When the bandage 
is brought back to the median line of the forehead it is 
reversed, and the reversed turn is held by the finger of the 
left hand while the roller is carried over the top of the 
head along the sagittal suture to a point just below the 
occipital protuberance ; here it is reversed again, and the 
reverse is held by an assistant while the roller is carried 
back to the forehead in an elliptical course, each turn cov- 




Oblique bandage of the angle of 
the jaw. 



48 BANDAGING. 

ering in two-thirds of the preceding turn. These turns 
are repeated with successive reverses at the forehead and 
occiput until one side of the head is completely covered in, 
and when this is accomplished a circular turn is made from 
the forehead to the occiput to hold the reverses in place. 

The opposite side of the head is next covered in by ellip- 
tical reversed turns made in the same manner, and when 
this has been accomplished two or three circular turns are 
carried around the head from the forehead to the occiput, 
to fix the preceding turns. Pins should be applied at the 




Recurrent bandage of the head. 

forehead and occiput at the points where the reversed turns 
concentrate (Fig. 43). 

Use. — This bandage when well applied is one of the 
neatest of the head-bandages, and it will be found useful 
to retain dressings to the vault of the cranium in the treat- 
ment of wounds of the scalp in this region. It will also 
be found of service in holding dressings to fractures of the 
cranium and to wounds after the operation of trephining. 
In restless patients it will sometimes become displaced, and 
it may be rendered more secure by pinning a strip of band- 
age to the circular turn in front of the ear and carrying 



BANDAGES OF THE HEAD. 



49 



Fig. 44. 



it down under the chin and up to a corresponding point 
on the opposite side, where it is pinned to the circular 
turn ; or one or two oblique turns passing from the circu- 
lar turn over the vertex of the skull downward behind 
the ear, under the chin and up to the circular turn in front 
of the ear, may be applied. The course of these turns is 
the same as those employed in the oblique bandage of the 
angle of the jaw, the extremity being secured by a pin. 

Transverse Recurrent Bandage of the Head. Boiler 
Two Inches in Width, Six Yards in Length. — The initial 
extremity of the roller is placed upon the lower part of the 
forehead and the bandage is 
carried twice around the head 
from the forehead to the occi- 
put to secure it. The head is 
then covered in by transverse 
turns of the bandage ; the first 
turn, starting from a point be- 
hind the ear on one side, is 
carried below the occiput to a 
corresponding point behind the 
opposite ear, and ascending 
transverse turns are then made 
and carried over the head, each 
turn covering in about two- 
thirds of the preceding turn, 
until the forehead is reached, 
and when this has been reached 
two or three circular turns are 

carried around the head from the forehead to the occiput 
to fix the recurrent turns. Pins should be applied at the 
points of starting and finishing of the reversed turns be- 
hind the ears, and at the occiput and forehead (Fig. 44). 

Use. — This bandage may be employed to secure dress- 
ings to the scalp in cases of wounds or in injuries to the 
skull, and is used for the same purposes as the recurrent 
bandage of the head. 

V-bandage of the Head. Roller Two Inches in Width, 
Four Yards in Length. — The initial extremity of the roller 




Transverse recurrent bandage of 
the head. 



50 



BANDAGING. 



is secured by two turns of the bandage around the cra- 
nium from the forehead to the occiput, and when the 
roller reaches the occipital protuberance it is allowed to 
drop a little below this, and is carried forward below 
the ear around the front of the chin and lower lip, then 
backward to the point of starting. These turns passing 
from the occiput to the forehead and from the occiput to 
the chin are alternately made until a sufficient number 
have been applied, and the extremity is secured by a pin 
over the occiput (Fig. 45). 



Fig. 45. 



Fig. 46. 




"\ -bandage c f the head. 



Head-and-neck bandage. 



This bandage may be modified by carrying the turns from 
the occiput forward under the ear and around the upper lip 
and back to the occiput, and alternating these turns with 
the occipitofrontal turns; if employed in this way, a band- 
age of one and one-half inches in width should be used. 

Use. — This bandage may be employed to hold dressings 
to the front of the chin, to the upper and lower lips in 
cases of wounds, or to give support to these parts after 
plastic operations. 

Head-and-neck Bandage. Roller Two Inches in Width, 
Four Yards in Length. — The initial extremity of the roller 
is placed upon the forehead and carried backward just 



BANDAGES OF THE HEAD. 



51 



above the ear to the occiput, and is then brought forward 
around the opposite side of the head to the point of start- 
ing. Two of these circular turns are made to fix the 
bandage, and when it is carried back to the occiput it is 
allowed to drop down slightly upon the neck, and is then 
carried around the neck, the turns around the head alter- 
nating with the neck-turns until a sufficient number of 
these have been applied, when the extremity of the bandage 
is secured by a pin at the point of crossing of the turns 
at the back of the head (Fig. 46). 

Use. — This bandage may be found useful in securing 
dressings to the anterior or posterior portion of the neck 
or to the region of the occiput. Care should be taken to 
apply it in such a manner that too much pressure is not 
made by the turns around the neck, which would be un- 
comfortable to the patient, and might seriously interfere 
with respiration. 

Crossed Bandage of One Eye. Roller Two Inches in 
Width, Four Yards in Length. — The initial extremity of 
the bandage is placed upon the forehead and fixed by two 
circular turns passing around the 
head from the occiput to the fore- 
head ; the roller is then carried 
back to the occiput and passed 
around this and brought forward 
below the ear, and passing over 
the outer portion of the cheek is 
carried upward to the junction of 
the nose with the forehead, and is 
then conducted over the parietal 
eminence downward to the occi- 
put ; a circular fronto-occipital 
turn is next made, and when the 
bandage is brought back to the oc- 
ciput it is brought forward again 
to the cheek. It should then ascend to the forehead, 
covering in two-thirds of the preceding turn, and again be 
conducted back to the occiput ; these turns are repeated, 
the oblique turns covering the eye alternating with circu- 




Crossed bandage of one eve. 



52 



BANDAGING. 



lar turns around the head until the eye is completely en- 
closed (Fig. 47). and the bandage is finished by making 
a circular turn about the head and introducing a pin to 
secure its extremity. It will be found more comfortable 
to the patient to include in the turns of the bandage the 
ear on the same side on which the eye is covered. 

Use. — This baudage will be found useful in retaining 
dressings to one eye. It will be more comfortable to the 
patient if a flannel roller be used to apply this bandage, as 
well as the bandage which includes both eyes. 

Crossed Bandage of Both Eyes. Roller Two Inches 
in Width, Six Yards in Length. — The initial extremity of 
the roller is placed upon the forehead and secured by two 
circular turns of the bandage passing around the head 
from the forehead to the occiput ; the roller is then carried 
dowmvard behind the occiput and brought forward below 
the ear to the upper portion of the cheek ; it is then car- 
ried upward to the junction of the nose with the forehead 
and conducted over the parietal eminence to the occiput ; 
a circular turn is now made around 
the head from the occiput to the 
forehead, and the roller is carried 
from the occiput over the parietal 
eminence of the opposite side for- 
ward to the junction of the nose 
with the forehead, then downward 
over the eye and outer portion of 
the cheek below the ear and back to 
the occiput; a circular turn around 
the head is next made, and this is 
followed by a repetition of the pre- 
vious turns, ascending over one eye, 
descending over the other eye, each 
turn alternating with a circular 
turn around the head. These turns 
are repeated until both eyes are covered in, and the band- 
age is finished by making a circular turn around the head, 
the extremity being secured by a. pin (Fig. 48). In this 
bandage both ears may be covered in or left uncovered. 




Crossed bandage of both eyes. 



BANDAGES OF THE HEAD. 



53 



Use. — This bandage may be used to apply dressings to 
both eyes, and both of these bandages covering the eyes 
are used where it is desired to make pressure ; but for the 
simple application of a light dressing or of a bandage for 
the exclusion of light, the Liebreich's bandage (Fig. 91) 
will be found more comfortable to the patient. 

OccipitO-facial Bandage. Boiler Two Inches in Width, 
Four Yards in Length. — The initial extremity of the roller 
is placed upon the vertex of the head and the bandage is 
carried downward in front of the ear, under the jaw, and 
upward upon the opposite side in the same line to the ver- 
tex ; two or three of these turns are made, one turn accu- 
rately covering in the other. A reverse should be made 
just above and in front of the ear, and two or three turns 
are then made around the head from the occiput to the 
forehead, which completes the bandage Fig. 49). Pins 
should be inserted at the points where the turn- of the 
bandage cross each other. 

Use. — This bandage is employed to secure dressings to 
the vertex, temporal, occipital, or frontal region. 



Fig. 49. 



Fig. 50. 





Occipitofacial bandage. 



Oblique bandage of the head. 



Oblique Bandage of the Head. Roller Two Inches in 
Width, Six Yards i,, Length. — The initial extremity of the 
bandage is placed upon the forehead, and is secured by 



54 



BAXDAGTXG. 



Fig 



two circular turns passing around the head from the fore- 
head to the occiput. From the occiput the bandage is 
carried obliquely over the highest part of the lateral aspect 
of the head, which is to be covered in, and is passed over 
the forehead and back to the occiput. It is then carried 
to the forehead by a circular turn, which is conducted 
obliquely over the other side of the head and back to the 
occiput. A circular turn from the occiput to the forehead 
should be made between the oblique turns. These turns 
are repeated, so that each succeeding turn covers in three- 
fourths of the preceding turn until the sides of the head 
are covered in by descending turns, and the bandage is 
completed by a circular turn passing around the head from 

the forehead to the occiput 
(Fig. 50). This bandage may 
be applied with descending or 
ascending turns. 

Use. — This bandage is em- 
ployed to make pressure upon 
or to hold a dressing to the 
lateral aspects of the head. 

Occipito-frontal Bandage. 
Boiler Two Inches in Width, 
Four Yards in Length. — The 
initial extremity of the roller 
is placed upon the forehead, 
and a circular turn is made 
around the forehead and occi- 
put to fix it. A circular turn 
is then made, passing around 
the head from a point below the occiput to a point just 
above the forehead ; the next circular turn is made around 
the head ascending posteriorly and descending anteriorly, 
and after a sufficient number of these turns have been 
made to cover in the front and back of the head the end 
of the bandage is secured with a pin (Fig. 51). 

Use. — This bandage will be found useful in securing 
dressings to the forehead and anterior and posterior por- 
tions of the scalp. 




Occipito-frontal bandage. 



BANDAGES OF THE UPPER EXTREMITY. 



55 



BANDAGES OF THE UPPER EXTREMITY. 



Spiral Bandage of the Finger. Boiler One Inch in 
Width, One and a Half Yards in Length — The initial ex- 
tremity of the roller is se- 
cured by two or three turns Fig. 52. 
around the wrist ; the 
bandage is then carried 
obliquely across the back 
of the hand to the base of 
the finger to be covered 
in, then to its tip by ob- 
lique turns ; a circular turn 
is next made, and the 
finger is covered by as- 
cending spiral or spiral 
reversed turns until its 
base is reached ; the band- 
age is then carried ob- 
liquely across the back of 
the hand and finished by 
one or two circular turn- 
around the wrist ; the ex- 
tremity may be pinned or 
may be split into two tails 
wrist (Fig. 52). 

Use. — This bandage is employed to retain dressings to 
injuries or wounds upon the finger, and to secure splints 
in the treatment of fractures or dislocations of the 
phalanges. 

Gauntlet Bandage. Boiler One Inch in Width, Three 
Yard* in Length. — The initial extremity of the roller is 
fixed at the wrist by one or two circular turns of the 
bandage ; it is then carried down to the tip of the thumb 
by an oblique turn of the roller, and this is covered in by 
spiral or spiral reversed turns to the metacarpo-phalangeal 
articulations ; the roller is then carried back to the wrist 
and a circular turn is made around it. The bandage is 




Bpiral bandage i I the 

which are tied around the 



56 



BANDAGING. 



then carried down to the tip of the index finger by an 
oblique turn, which is covered in the same manner. When 
all the fingers have been covered in, the bandage is finished 
by circular turns around the hand and wrist (Fig. 53). 

Use. — This bandage may be employed to apply dressings 
to the fingers and hand in cases of wounds or fractures. 
It was formerly much employed in the treatment of burns 
of the fingers to prevent the opposed ulcerated surfaces 
from adhering, but its use for this purpose has been sup- 
planted by wrapping each finger in a separate dressing and 
applying a bandage over all the fingers and the hand with a 
few recurrent and spiral turns of a wide roller, the applica- 
tion of this dressing being much less painful to the patient, 





Fig. 


53. 


^m 1 




■ft ^ft. ▼ 


V^P%7*fl 


&. ^ 




k 
















Ipfl 



Fig. 54. 



Gauntlet bandage. 




auntlet bandage. 



and being at the same time equally satisfactory in its 
results. 

Demi-gauntlet Bandage. Boiler One Inch in Width, 
Four Yards in Length. — The initial extremity of the 
bandage should be placed upon the wrist and fixed by two 
circular turns passing from the radial to the ulnar side ; 



BANDAGES OF THE UPPER EXTREMITY. 



57 



then carry the roller obliquely across the back of the hand 
to the base of the little finger, pass the bandage around this 
and carry the roller back to the wrist, making a circular 
turn ; it should then be carried obliquely across the hand to 
the base of the ring finger, and so successively until the base 
of each of the fingers and of the thumb has been included ; 
the bandage is then completed by an oblique turn across the 
back of the hand, passing between the index finger and the 
thumb, and a circular turn around the wrist (Fig. 54). 

The demi-gauntlet bandage may also be applied in such 
a manner as to cover only the palm and leave the dorsum 
of the hand uncovered. 

Use. — This bandage may be employed to retain light 
dressings to the dorsal or palmar surface of the hand. 

Spica-bandage of the Thumb. Holler One Inch in 
Width, Three Yards in Length. — The initial extremity of 
the roller is placed upon the wrist 
and fixed by two circular turns ; 
then carry the roller obliquely over 
the dorsal surface of the thumb to its 
distal extremity ; next make a circu- 
lar or spiral turn around the thumb, 
and carry the bandage upward over 
the back of the thumb to the wrist, 
around which a circular turn should 
be made. The roller is then carried 
around the thumb and wrist, making 
figure-of-eight turns, each turn over- 
lapping the previous one two-thirds 
as it ascends the thumb, and each 
figure-of-eight turn alternating with 
a circular turn around the wrist. 
These turns are repeated until the 
thumb is completely covered in with spica-turns ; a circular 
turn around the wrist finishing the bandage (Fig. 55). 

Use. — This bandage is employed to apply dressings to 
the dorsal surface of the thumb and for the retention of 
splints in the dressing of fractures or dislocations of the 
bones of the thumb. 




Spica bandage of the tlnimb. 



58 



£ AND AGING. 



Spiral Reversed Bandage of the Upper Extremity. 
Roller Tiro and a Half Inches in Width, Seven Yards in 

Length. — The initial extremity of the roller is placed upon 
the wrist, and secured by two turns around the wrist ; the 
bandage is then carried obliquely across the back of the 
hand to the second joint of the fingers, where a circular 
turn should be made ; the hand is covered in bv two or 



Fig. 56. 




Spiral reversed bandage of the upper extremity. 

three ascending spiral or spiral reversed turns. AVhen the 
thumb has been reached, its base and the wrist are covered 
in by two figure-of-eight turns ; the bandage is then carried 
up the forearm by spiral and spiral reversed turns until the 
elbow is reached; this may be covered in with spiral re- 
versed turns, and the bandage is next carried up the arm 
with spiral reversed turns to the axilla (Fig. 56). If, on 
reaching the elbow, the arm is bent, or is to be flexed in 
the subsequent dressing, the elbow should be covered in 
with figure-of-eight turns, and when this has been done 
the arm may be covered in with spiral reversed turns. 
When properly applied, the reverses should be in line, 
and should not be made over the prominent ridge of the 
ulna. 

Use. — This is one of the most generally employed of all 
the roller-bandages ; it constitutes the primary roller which 
is applied in the dressing of fractures of the humerus, and 



BANDAGES OF THE UPPER EXTREMITY. 



59 



it is also the bandage employed in holding dressings to the 
arm and forearm and in securing splints to these parts in 
the treatment of fractures and dislocations. 

Figure-of-eight Bandage of the Elbow, Roller Two 
Inches in Width, Four Yards in Length. — The initial ex- 
tremity of the bandage is placed upon the forearm a short 
distance below the elbow-joint, and fixed by one or two 

Fig. 57. 




Figure-of-eight bandage of the elbow. 

circular turns, the arm being flexed. The bandage is then 
carried by an oblique turn across the flexure of the elbow- 
joint, and passed around the arm a few inches above the 
elbow ; a circular turn is then made, and the roller is next 
carried across the flexure of the elbow and passed around 
the forearm. These turns are repeated, the turns from the 
forearm ascending and those from the arm descending, 
each set of turns crossing in the flexure of the elbow until 



60 



BANDAGING. 



it is covered in, and a final turn is passed circularly around 
the elbow-joint (Fig. 57). This bandage is sometimes 
applied by first making one or two circular turns around 
the elbow and then applying the figure-of-eight turns as 
previously described (Fig. 58). 

Use. — This bandage is often employed as a part of the 
spiral reversed bandage of the upper extremity when the 
arm is to be flexed, and is also used to hold dressings to 
the region of the elbow-joint. It was formerly much used 

Fig. 58. 




Figure-of eight bandage with primary turns around the elbow. 

to hold the compress upon the wound resulting from vene- 
section at the elbow. 

Spica-bandage of the Shoulder (Ascending). Roller 
Two and a Half Inches in Width, Seven Yards in Length. 
— The initial extremity of the roller is placed obliquely 
upon the outer surface of the arm opposite the axillary 
fold, and fixed by one or two circular turns. If the right 
shoulder is to be covered, the bandage is next carried across 
the front of the chest to the axilla of the opposite side, 
then around the back of the chest to the point of starting 



BANDAGES OF THE UPPER EXTREMITY. 61 

upon the arm ; then the roller should be conducted around 
the arm of this side up over the shoulder, across the front 
of the chest, through the opposite axilla, and back over the 
posterior surface of the chest to the point of starting ; con- 
tinue to make these ascending turns, each turn overlapping 
the preceding one about two-thirds until the shoulder is 
covered in (Fig. 59), when the extremity of the bandage 
may be secured by a pin at the point of ending, or the last 
turn may be carried from the shoulder around the back of 
the neck and brought forward over the opposite shoulder 



Spica-bandage of the shoulder (ascending). 

and pinned to the turns which pass around the axilla. It 
should be remembered that the turns of the roller overlap 
each other exactly in the opposite axilla, and it will be 
found more comfortable to the patient to place a little 
cotton-wadding in the axilla to prevent the bandage from 
excoriating the skin of this part. Care should be taken 
to see that the turns are made in such a manner that the 
spica-turns occupy as nearly as possible the median line 
of the shoulder. When this bandage is applied to the 
left shoulder, after fixing the initial extremity by circular 
turns around the arm, the roller should be carried over 



62 BANDAGING. 

the back of the chest to the axilla of the opposite side and 
then brought back to the point of starting ; the succeed- 
ing turns are then applied in the same manner. 

Spica-bandage of the Shoulder (Descending). Roller 
Two and a Half Inches in Width, Seven Yards in Length. — 
The initial extremity of the roller should be fixed upon 
the arm as near as possible to the axillary fold by one or 
two circular turns ; and if it is applied to the right shoul- 
der, the bandage should be passed under the axilla and 
carried obliquely over the shoulder to the base of the neck, 

Fig, 60. 




(descending). 



then downward across the front of the chest to the axilla 
of the opposite side ; from the axilla the roller is carried 
over the back of the chest to the base of the neck, so as to 
cross the first turn at this point ; it is then carried through 
the axillary space, then back to the neck, the turns de- 
scending toward the shoulder. These turns, taking the 
same course, are repeated, each turn overlapping two- 
thirds of the previous one until the shoulder is covered in 
and the circular turn around the arm is reached, at which 
point the extremity is secured by a pin (Fig. 60). 

Use. — The spica-bandages of the shoulder are employed 




BANDAGES OF THE UPPER EXTREMITY. 63 

to hold dressings to the shoulder, to hold compresses over 
the acromial end of the clavicle in dislocation of that 
portion of the bone, to retain the shoulder-cap used in 
the treatment of fractures of the upper portion of the 
humerus, and to retain dress- 
ings to the axilla. Fig. 61. 

Figure-of-eight Bandage 
of the Neck and Axilla. 
Roller Two Inches in Width, 
Five Yards in Length. — The 
initial extremity of the roller 
is fixed upon the side of the 
neck and secured by one or 
two loosely applied circular 
turns; if applied to the right 
axilla, carrv the bandage from 

i r», , ■ "i , ,i * l i. Figure-of-eight bandage of the 

left tO right Over the right neck and axilla. 

shoulder to the posterior part 

of the axilla under which it passes, to ascend in front over 
the same shoulder to the back of the neck ; these figure- 
of-eight turns around the neck and axilla, each turn over- 
lapping two-thirds of the preceding turn, are repeated 
until the desired space is covered and the bandage is 
completed by a circular turn around the neck (Fig. 61). 

Use. — This will be found a useful bandage to secure 
dressings to the base of the neck, the upper part of the 
shoulder, and to the axilla, as it does not restrict the 
motions of the arm unless drawn too tight. 

Velpeau's Bandage. Two Rollers Two and a Half 
Inches in Width, Seven Yards in Length. — The patient 
should place the fingers of the haud of the affected side on 
the opposite shoulder ; the initial end of the roller should 
be placed on the body of the scapula of the sound side 
and secured by a turn made by carrying the bandage over 
the shoulder of the affected side, near its outer portion, 
then conducting it downward over the outer and posterior 
surface of the arm of the same side, behind the point of 
the elbow, and obliquely across the front of the chest to 
the axilla of the opposite side, thence to the point of start- 



64 



BANDAGING. 



ing. This turn should be repeated, to fix the initial ex- 
tremity of the bandage. Having completed the second 
turn, carry the roller transversely around the thorax, pass- 
ing over the flexed elbow of the aifected side, from this 
point to the axilla, and through this to the back. From 
this point the roller is carried over the shoulder and 
down the outer and posterior surface of the arm behind the 
elbow, and obliquely across the front of the chest through 
the axilla to the back, and, continuing, passes transversely 

Fig. 62. 




Velpeau's bandage. 



across the back of the chest to the elbow, which it en- 
circles, and then passes to the axilla. These alternating 
turns are repeated until the arm and forearm are bound 
firmly to the side and chest. The vertical turns over the 
shoulder, each turn covering in two-thirds of the previous 
turn and ascending from the point of the shoulder toward 
the neck and from the posterior surface of the arm toward 
the elbow, are applied until the point of the elbow is 
reached. The transverse turns passing around the chest 
and arm are so applied that they ascend from the point 
of the elbow toward the shoulder, each turn covering in 



BAXDAGES OF THE UPPER EXTREMITY. 65 

one-third of the previous one, and the last turn should 
pass transversely around the shoulder and chest, covering 
the wrist (Fig. 62 1. 

The extremity of the bandage should be secured by a 
pin where it ends, and additional fixation will be secured 
by introducing a number of pins at the points where the 
turns of the bandage cross each other. 

Use. — This bandage is employed to fix the arm in the 
treatment of certain fractures of the clavicle and scapula ; 
also to secure fixation of the humerus after the reduction 
of dislocations of the shoulder-joint. 

Desault's Bandage. Three Rollers Tiro and a Half 
Inches in Width. SevenYards in Length. — A wedge-shaped 
pad to fit in the axilla is also required. These rollers are 
known as the first, second, and third rollers. 

First Roller of Desault's Bandage. — Before applying the 
first roller the arm of the patient on the injured side should 

Fig. C3. 




First roller of Desault's bandage. 

be elevated and carried off at right angles to the body ; the 
wedge-shaped pad with its base in the axilla should next 
be applied to the side of the chest, and the initial extrem- 
ity of the roller should be placed upon the middle of the 
pad, which may be fixed by two or three circular turns 
around the chest ; the bandage is then carried down the 



66 



BANDAGING. 



chest by oblique circular turns until the lower extremity 
of the pad is reached, and it is then carried up the chest 
by spiral turns until the upper extremity of the pad is 
reached, when it is conducted obliquely across the front 
of the chest to the sound shoulder and passed under the 
axilla, brought over the shoulder and conducted around 
the chest, where it is secured (Fig. 63). 

Second Roller of Desault's Bandage. — The arm should be 
brought down against the side so as to press upon the pad 
previously applied, and the forearm should be flexed upon 
the arm and brought across the lower portion of the chest. 

Fig. 64. 




Second roller of Desault's bandage. 






The initial extremity of the roller is placed in the axilla 
of the sound side, and the bandage is carried around the 
chest and over the arm of the injured side, making a cir- 
cular turn around the chest to fix it ; then spiral turns are 
made around the chest from above downward until the 
elbow is reached, the turns being more firmly applied as 
they descend, and when this point is reached the end of 
the bandage is secured. Or the initial extremity of the 
bandage may be placed upon the chest of the sound side 
and a circular turn may be made to fix it, and then spiral 
turns, including the chest and arm, may be made from 
below upward until the axilla is reached (Fig. 64). 



BANDAGES OF THE UPPER EXTREMITY. 67 

Third Roller of Desault's Bandage. — The initial extremity 
of the roller is placed in the axilla of the sound side, and 
the bandage is carried obliquely over the front of the chest 
to the shoulder of the injured side, passed over this, and 
conducted down the back of the arm to the elbow, thence 
obliquely upward over the upper fifth of the forearm to 
the axilla of the sound side. From this point it is carried 
backward obliquely over the back of the chest to the shoul- 
der ; crossing the previous shoulder-turn, it is conducted 
down the front of the arm to the elbow, then around this 
and backward obliquely over the back of the chest to the 

Fig. 65. 




Third roller of Desault's band 



axilla of the sound side. These turns are repeated until 
three sets of turns have been applied, which should overlie 
each other exactly (Fig. 65). The course of the turns of 
the third roller is considered the most difficult to remem- 
ber, and the student may be assisted in its correct applica- 
tion by remembering that all the turns start at the axilla, 
pass to the shoulder, and then to the elbow, and from the 
elbow always return to the starting-point — the axilla. 
The turns of the third roller make two triangles, one on 
the anterior surface of the chest (Fig. 6Q), the other upon 
the back (Fig. 67). 

After the application of the three rollers the hand and 



68 



BAXDAGISG. 



uncovered portion of the forearm should be supported in 
a sling suspended from the neck. 

Use. — This bandage, applied completely, or some one of 
its various rollers, is employed in the treatment of fractures 
of the clavicle. 




Anterior view of the turns of third 
roller of Desault's bandage. 



Posterior view of the turns of third 
roller of Desault's bandage. 



Arm-and- chest Bandage. Boiler Two and a Half 

Inches in Width, Seven Yards in Length. — Before applying 
this bandage, the arm should be placed against the side of 
the chest and a folded towel or a pad of cotton should be 
placed in the axilla and allowed to extend from the axilla 
to the elbow ; the latter is used to prevent the opposing 
surfaces of skin from becoming excoriated by contact. 



BANDAGES OF THE UPPER EXTREMITY. 



69 



The initial extremity of the bandage is placed upon the 
spine at a point opposite the elbow-joint, and it is fixed by 
a turn or two passing around the arm and chest ; the band- 
age is then continued by making ascending spiral turns, 
covering in the arm and chest until the axilla is reached ; 
at this point the bandage is carried through the axilla of 
the sound side and over the back of the chest to the top of 



Fig, 




Arm-and-chest bandage. 

the opposite shoulder, and it is then conducted down the 
front of the arm to the elbow, is passed between the arm 
and chest, and carried up the back of the arm to the 
shoulder. It is then passed obliquely across the front of 
the chest, and is secured upon the back of the chest. Pins 
should be introduced at the points of crossing of the 
bandage (Fig. 68). 



70 



BANDAGING. 



Use. — This bandage will be found useful in fixing the 
arm to the body and in fixing the shoulder-joint where it 
is desirable to allow the forearm to be free. It is em- 
ployed in the treatment of fractures of the shaft and neck 
of the humerus to fix the arm and hold splints in position. 



Fig. 69. 



BANDAGES OF THE TRUNK. 

Spiral Bandage of the Chest. Roller Three Inches in 
Width, Nine Yards in Length. — The initial extremity of 
the roller is applied to the anterior portion of the waist, 
and fixed by one or two circular turns ; the bandage is 
then carried upward, encircling the chest by ascending 
spiral turns, each turn covering in one-half of the previous 
turn until the axillary fold is reached ; the roller is next 
carried around the axilla to the back, and obliquely over 
this to the base of the neck of the opposite side, and 
then it may be passed down over the chest and pinned 
to the spiral turns at several points ; a pin should also be 
inserted at the point w 7 here the last turn of the roller 
leaves the spiral turn upon the back of the chest (Fig. 69). 

Use. — This bandage is em- 
ployed to hold dressings to 
the chest, and may be used 
as a temporary dressing in 
fractures of the ribs or ster- 
num. Care should be taken 
that the bandage be not so 
tightly applied as to interfere 
with respiration. 

Anterior Figure-of-eight 
Bandage of the Chest. 
Roller Two and a Half Inches 
in Width, Seven Yards in 
Length. — The initial extrem- 
ity of the roller should be 

placed in the axilla of One Spiral bandage of the chest. 

side, and the bandage is then 

carried obliquely across the anterior portion of the chest 





BANDAGES OF THE TRUNK 



71 



to the shoulder of the opposite side ; it is then carried 
backward around the shoulder and through the axilla, and 
is next conducted obliquely over the anterior portion of 
the chest to the opposite shoulder, through the axilla, and 
again back to the anterior portion of the chest, the turns 
crossing in the median line over the sternum. These 
turns should be repeated, ascending from the shoulder 
toward the neck, each turn overlapping three-fourths of 
the preceding one, until five or six turns have been ap- 
plied, the end of the bandage being secured by a pin 

Fig. 70. 




Anterior figure-of-eight bandage of the chest. 



(Fig. 70), or it may be completed by a circular turn 
around the chest. 

Use. — This bandage may be employed to bring the 
shoulders forward, and to hold dressings to the anterior 
portion of the chest. 

Posterior Figure-of-eight Bandage of the Chest. 
Roller Two and a Half Inches in Width, Seven Yards in 
Length. — The initial extremity of the roller should be 
placed in the axilla of the left side, and the bandage should 
then be carried obliquely across the back of the chest to 
the top of the opposite shoulder ; it is next carried through 
the axilla and conducted across the posterior portion of the 
chest to the top of the opposite shoulder, and passed through 
the axilla to the point of starting. These turns are re- 



72 BANDAGING. 

peated, descending from the neck toward the shoulder, until 
five or six have been applied, the end of the bandage being 
secured by a pin (Fig. 71). In applying both of these 
bandages the crosses of the bandage, either anterior or 
posterior, should be made in the median line of the 
chest. '.{'-..' 

Use. — This bandage may be employed to hold dress- 
ings to the posterior portion of the chest and to draw the 
shoulders backward. 

Fig. 71. 




Posterior figure-of-eight bandage of the chest. 

Suspensory and Compressor Bandage of the Breast. 

Roller Two and a Half Inches in Width, Seven Yards in 
Length. — The initial extremity of the roller should be 
placed upon the scapula of the affected side, and secured 
by two oblique turns carried over the opposite shoulder 
and conducted downward under the breast to be covered 
in, and then carried to the axilla of the same side. Next 
carry the roller transversely around the chest, covering in 
the lowest portion of the affected breast. These turns 
should be repeated, the oblique turns from the axilla over 
the shoulder alternating with the transverse turns around 
the chest, until the breast is covered in, each series of turns 
ascending and covering two-thirds of the preceding turns 
(Fig. 72). 



BANDAGES OF THE TRUNK. 



73 



Use. — This bandage is employed to support the breast 
and to make compression at the same time ; it may also be 
employed to hold dressings to the breast. 



Fig. 72. 




Suspensory and compressor bandage Of the breast. 



Suspensory and Compressor Bandage of Both 
Breasts. Two Boilers Two and a Half Inches in Width, 
Seven Yards in Length. — The initial extremity of the 
bandage should be secured by oblique turns of the axilla 
and shoulder, passing under one breast, as in the preceding 
bandage ; the roller should next be carried transversely 
around the back to the other breast, then under the breast 
and upward over the opposite shoulder, then obliquely 
downward around the chest to the other side, being carried 
transversely over the lower portion of both breasts to the 
point of starting upon the back. Repeat these oblique 
turns from the shoulder to the breast and from the breast 
to the shoulder, and alternate them with a transverse 
turn around the chest and over both breasts. Both series 
of turns should ascend, and each turn should overlap 
two-thirds of the preceding one (Fig. 73). 

Use. — This bandage is employed to support and com- 
press both breasts and to retain dressings to them. 



74 



BANDAGING. 





\ 




Suspensory and compressor bandage of both breasts. 

BANDAGES OF THE LOWER EXTREMITY. 

Single Spica-bandage of the Groin (Ascending). 

Roller Two and a Half Inches in Width, Seven Yards in 
Length. — Place the initial extremity of the bandage upon 
the anterior portion of the right thigh just below the groin, 
and secure it by one or two circular turns around the thigh, 
or place the initial extremity of the roller obliquely upon 
the upper part of the thigh and carry it behind the limb 
and upward around the outer side of the thigh to the abdo- 
men, omitting the circular turns ; then carry the bandage 



BANDAGES OF THE LOWER EXTREMITY. 



75 



obliquely across the lower part of the abdomen to a point 
just below the crest of the left ilium, and conduct it trans- 
versely around the back of the pelvis to a corresponding 
point on the opposite side ; then bring it obliquely down- 
ward to the groin and over to the inner portion of the thigh, 
carrying it around the limb, crossing the starting-turn in 
the middle line of the thigh. These turns are repeated, 
each turn ascending and covering in two-thirds of the pre- 
ceding turn, until six or eight complete turns have been 
made, and the bandage is then secured at any point where 
it ends (Fig. 74). This bandage may also be applied by 



Ftg. 74. 




Ascending spica-bandage of the groin 



placing the initial extremity of the bandage just below the 
anterior superior spinous process of the ilium, and making 
two turns around the pelvis and then carrying the bandage 
to the thigh below the groin, passing it behind the thigh, 
bringing it up on the opposite side of the thigh to cross 
the first turn in the middle line of the groin ; ascending 
spica-turns are then made until a sufficient number have 



76 



BANDAGING. 



been applied to cover in the groin to the desired extent 
(Fig. 75). This bandage possesses the advantage that it 
is less likely to become displaced than the one previously 
described. 

Single Spica-bandage of the Groin (Descending). 
Roller^ Two and a Half Inches in Width, Seven Yards in 
Length. — Place the initial extremity of the roller obliquely 
upon the anterior surface of the right thigh and secure it 
by one or two circular turns around the limb, or start the 
bandage with an oblique turn, as previously described ; 
then carry the bandage obliquely across the abdomen to 
a point just below the crest of the ilium, and conduct it 
transversely around the back of the pelvis to a correspond- 
ing point on the opposite side ; then bring it obliquely 

Fig. 75. 




Ascending spica-bandage of the groin applied with pelvic turns. 

down over the lower portion of the abdomen, crossing the 
first turn, to the junction of the thigh with the scrotum, 
pass it under the thigh and bring it up over the lower 
part of the abdomen, and let it follow the course of the first 
turn. These turns are repeated, each turn descending and 
overlapping two-thirds of the preceding turn until the groin 
is covered (Fig. 76). When either of these bandages is 
applied to the left groin, after the initial extremity of the 



BANDAGES OF THE LOWER EXTREMITY. 



77 



roller is fixed, it is carried first to the crest of the ilium 
of the same side, then around the back of the pelvis to a 
corresponding point on the opposite side, then obliquely 
across the lower part of the abdomen to the outer aspect 
of the thigh, being conveyed around this and brought up 
between the thigh and the scrotum, passing obliquely over 
the groin to follow the course of the original turn. This 
bandage may also be applied by making one or two cir- 
cular turns around the pelvis, and the groin is next cov- 
ered in by descending spica-turns. 

Double Spica-bandage of the Groins. Roller Three 
Inches in Width, Nine 'Yards in Length. — The initial ex- 
tremity of the roller is placed upon the abdomen just above 

Fig. 76. 




Descending spica-bandage of the groin. 



the iliac crests and secured by one or two circular turns : 
the bandage is then carried from a point just below the 
crest of the right ilium obliquely across the lower por- 
tion of the abdomen to the outer portion of the left 
thigh, is carried around this and brought up between 
the scrotum and the thigh, and is passed obliquely over 
the groin, crossing the previous turn in the median line, 
and is conducted to a point just below the crest of the 
ilium on the same side. The bandage is then continued 



78 



BANDAGING. 



around the pelvis to the same point on the opposite side, 
and from this point is made to pass obliquely over the 
groin to the inner side of the right thigh, passing around 
this and coming up on its outer side, crossing the preceding 
turn at the middle line of the groin, to be carried obliquely 
across the groin and lower part of the abdomen to the 
crest of the ilium on the opposite side. These turns are 
repeated, each turn covering in two-thirds of the previous 
turn, until both groins have been covered (Fig. 77). The 
turns may be so applied as to ascend or descend, forming 
the ascending or descending double spica-bandage of the 

Fig. 77. 




Double spica-bandage of the groins. 

groins. When properly applied, this bandage presents 
three sets of crossing-turns, one in each groin and one in 
the median line of the abdomen. 

Use. — The spica-bandages of the groin, either single or 
double, are employed to hold dressings to wounds in the 
inguinal region — for instance, those resulting from herni- 
otomy, or from operations upon the glands of the groin. 
They are also employed to make pressure upon this region, 
and will often prove of use in the securing of compresses 
applied for the temporary retention of herniae. 



BANDAGES OF THE LOWER EXTREMITY. 



79 



Fig 




Spica-bandage of Buttock. Roller Two and a Half 
Inches in Width, Seven Yards in Length. — The initial ex- 
tremity of the bandage is 
placed upon the back of the 
thigh just below the gluteal 
fold, and is carried around the 
thigh and brought back to the 
posterior aspect of the limb, so 
as to fix and cross the starting- 
turn near the middle of the 
thigh. It is next conducted 
obliquely across the thigh and 
buttocks and carried to the 
brim of the pelvis of the op- 
posite side, when it is brought 
obliquely over the abdomen 
and back to the posterior sur- 
face of the thigh. These as- 
cending turns are applied, 
each turn covering in about 
three-fourths of the preced- 
ing one, until the buttock is 
covered, and the bandage is then finished by one or two 
circular turns around the pelvis and abdomen (Fig. 78). 

Use. — This bandage is employed to hold dressings to the 
upper posterior portion of the thigh, or the buttock. 

Figure-of-eight Bandage of the Knee. Bolter Two 
and a Half Inches in Width, Five Yards i)i Length. — The 
initial extremity of the roller is placed upon the left thigh 
three inches above the patella and secured by two or three 
circular turns ; then conduct the bandage over the outer 
condyle of the femur across the popliteal space to the inner 
border of the tibia and around the anterior surface below 
the tubercle and head of the fibula, and make one circular 
turn ; the roller should then be carried obliquely across the 
popliteal space to the inner condyle of the femur, crossing 
the previous turn ; then carry it around the front of the 
thigh to the outer condyle ; repeat these turns, ascending 
toward the knee from the leg and descending from the 




Spica-bandage of buttock. 



80 BANDAGING. 

thigh toward the knee, and finish the bandage by a circular 
turn over the patella (Fig. 79). 

This bandage may also be applied by making two circu- 

Fig. 79. 




Figure-of-eight bandage of the knee. 
Fig. £0. 




Figure-of-eight bandage of the knee. 



lar turns around the patella and popliteal space, and then 
carrying the bandage to the thigh three inches above the 
patella, and finishing it with descending turns from the 



BANDAGES OF THE LOWER EXTREMITY. 



81 



Fig. 81. 



thigh and ascending turns from the head of the tibia, mak- 
ing all turns cross in the popliteal space (Fig. 80). 

Use. — This bandage is employed to hold dressings to the 
knee-joint either anteriorly or posteriorly. These figure- 
of-eight turns are often employed in covering the knee in 
applying the spiral reversed bandage of the lower ex- 
tremity when it is desired that the patient be allowed to 
bend the knee. 

Figure-of-eight Bandage of Both Knees. Boiler Two 
and a Half Inches in Width, Seven Yards in Length. — Place 
the knees of the patient together with a compress between 
them ; then place the initial extremity of the roller upon 
one thigh, about three inches above the patella, and se- 
cure it by one or two circular turns around both thighs ; 
then conduct the roller 
from the outer condyle of 
the left femur obliquely 
across the popliteal spaces 
of both legs to the head 
of the fibula on the 
opposite side, making a 
circular turn around both 
legs ; pass the roller from 
the head of the fibula on 
the opposite side across 
the popliteal space to the 
external condyle opposite 
the point of starting. 

Repeat these turns, descending from the thighs and 
ascending from the legs, until the knees are covered, 
and finish the bandage by carrying a turn of the bandage 
at right angles to the preceding turns between the thighs 
and the legs (Fig. 81). 

Use. — This bandage is employed to secure fixation of 
the limbs after operations upon the perineum, and may also 
be employed to obtain temporary fixation of the limbs in 
transporting cases of fracture of the femur, and after the 
reduction of dislocations of the head of that bone. 

Spica-bandage of the Foot. Bolter Two and a Half 




Figure-of-eight bandage of both knees. 



82 



BANDAGING. 



Inches in Width, Five Yards in Length. — Fix the initial 
extremity of the roller upon the ankle and secure it by 
two circular turns ; then carry the bandage obliquely over 
the dorsum of the foot to the metatarso-phalangeal articu- 
lation, and make a circular turn around the foot at this 
point ; then continue it upward over the metatarsus by 
making two or three spiral reversed turns ; next carry the 
bandage parallel with the inner or outer margin of the sole 
of the foot, according to whether it is applied to the right 
or left foot, directly across the posterior surface of the 
heel ; thence along the opposite border of the foot and 

Fig. 82. 




Spica-bandage of the foot. 



over the dorsum, crossing the original turn in the median 
line of the foot. This completes the first spica-turn. These 
spica-turns are repeated, gradually ascending by allowing 
each turn to cover in three-fourths of the preceding turn, 
until the foot is covered in with the exception of the pos- 
terior portion of the sole of the heel (Fig. 82). Care should 
be taken to see that the turns cross each other in the median 
line, and that they are kept parallel to each other throughout 
their course. 

Use. — This bandage will be found very useful when 



BANDAGES OF THE LOWER EXTREMITY. 



83 



it is desired to make firm compression upon the foot 
or to retain dressings to it ; it is especially useful in 
the treatment of sprains of the ankle or the anterior 
tarsus. 

Bandage of Foot Covering the Heel (American). 
Roller Two and a Half Inches in Width, Seven Yards in 
Length. — The initial extremity of the roller is placed upon 
the leg just above the malleoli and fixed by two circular 
turns around the leg ; the bandage is then carried obliquely 
across the dorsum of the foot to the metatarso-phalangeal 
articulation, at which point a circular turn is made ; two 



Fig. 83. 



Fig. 84. 




Bandage of foot covering the heel. Turns covering heel in American bandage. 



or three spiral or spiral reversed turns are then made, 
ascending the foot ; the roller is next carried directly over 
the point of the heel and continued back to the dorsum of 
the foot ; thence beneath the instep around one side of the 
heel and up over the instep ; from this point it is carried 
beneath the instep around the other side of the heel (Fig. 
84) and up in front of the ankle, from which point it may 
be continued up the leg (Fig. 83). 

Use. — This bandage is employed to cover in the foot, 
and retain dressings to the foot and heel. 



84 



BANDAGING. 



Bandage of Foot Not Covering the Heel (French). 

Roller Two and a Half Inches in Width, Seven Yards in 
Length. — Fix the initial extremity of the roller upon the 
leg just above the malleoli and secure it by two circular 
turns around the leg ; the bandage is then carried obliquely 
across the dorsum of the foot to the metatarso-phalangeal 
articulation, and at this point a circular turn should be 
made. The roller is now carried up the foot, covering it 
in with two or three spiral reversed turns, and at this 
point a figure-of-eight turn is made around the ankle and 
instep ; this should be repeated once, which will cover in 
the foot with the exception of the heel ; the bandage may 

Fig. 85. 




Bandage of foot not covering the heel. 



then be continued up the leg with spiral reversed turns 
(Fig. 85). 

Use. — This bandage may be employed to secure dressings 
to the foot, and is the one generally used to cover this part 
in applying the spiral reversed bandage of the lower 
extremity. 

Spiral Reversed Bandage of the Lower Extremity. 
Holler Two and a Half Inches in Width, Seven Yards in 
Length. — The initial extremity of the roller is placed 
upon the leg just above the malleoli and secured by 
two circular turns. It is then carried obliquely over 



BANDAGES OF THE LOWER EXTREMITY. 85 

the foot to the metatarsophalangeal articulation, where 
a circular turn is made around the foot. Two or three 
spiral reversed and two figure-of-eight turns of the 
ankle and instep should be made, while just above the 
ankle one or two circular or spiral turns are made around 
the leg, and as the bandage is carried up the leg, as it 
increases in diameter, spiral reversed turns are made until 
it approaches the knee ; at this point, if the limb is to be 
kept straight, the spiral reversed turns may be continued 
over this region and up upon the thigh. If the knee is 
to be bent, figure-of-eight turns may be applied until the 
knee is covered, and then the thigh may be covered with 
spiral reversed turns (Fig. 86). To cover in the thigh as 

Fig. 86. 




Spiral reversed bandage of the lower extremity. 

well as the leg, two bandages of the dimensions before 
given will be required. Care should be taken to keep 
the reverses in a line, and not to make them over the 
spine of the tibia, as they may thus become painful to 
the patient. 

Use. — This is one of the most frequently employed of 
the roller-bandages ; it is used to apply pressure to the 
lower extremity, to retain dressings, and to secure splints in 
the treatment of fractures and dislocations. 

Figure-of-eight Bandage of the Leg. Roller Two and 
a Half Inches in Width, Seven Yards in Length. — This 
bandage differs from the spiral reversed bandage of the 



86 



BANDAGING. 



lower extremity only in the fact that when the swell of 
the calf is reached figure-of-eight tarns are made around 
the leg instead of spiral reversed turns. In aj3plying the 
roller, when the calf of the leg is reached the bandage is 
carried obliquely around the leg to the crest of the tibia 
and then made to cross the starting-turn in the median 
line ; these descending and ascending turns are repeated 
until the calf of the leg has been covered in, and the band- 

Fig. 87. 




Figure-of-eight bandage of the leg, 



age is finished with one or two circular turns just below 
the knee (Fig. 87). 

Use. — This bandage holds its place more firmly than 
the ordinary spiral reversed bandage of the leg, and may 
be employed in the treatment of ulcers of the leg in con- 
junction with strapping, where it is desirable to change the 
dressings at infrequent intervals and to allow the patient 
to walk about during the course of treatment. 



SPECIAL BANDAGES. 



87 



SPECIAL BANDAGES. 

Spiral Reversed Bandage of the Penis. Roller Three- 
quarters of an Inch in Width, Thirty Inches in Length. — 
Fix the initial extremity of the roller by two circular 
turns around the penis close -p 

to the pubis ; then carry the 
bandage obliquely down to 
the corona glandis; from this 
point ascend the body of the 
penis by spiral reversed turns 
to the pubis, and finish the 
bandage by two figure-of- 
eight turns around the neck 
of the scrotum and root of the 
penis, or split the end of the 
bandage so as to form two 
tails, and secure it by tying 
these around the root of the 
penis (Fig. 88). 

Recurrent Bandage of a 
Stump. Roller Two and a 
Half Inches in Width, Five 
to Seven Yards in Length. 
— Place the initial extremity of the roller upon the ante- 
rior or posterior surface of the limb a few inches above the 
extremity of the stump, and carry the bandage to the end 
of the stump, and then conduct it upward or downward 
on the limb, as the case may be, to a point directly oppo- 
site the point of starting ; then bring the bandage back- 
over the face of the stump to the point of starting, and 
continue these recurrent turns, each turn overlapping two- 
thirds of the preceding one, until the face of the stump is 
covered ; then reverse the bandage and secure the recur- 
rent turns at their points of origin by two or three circular 
turns. The roller should next be carried obliquely down to 
the end of the stump, and a circular turn should be made 
around this. The bandage should then be carried up the 
limb by spiral or spiral reversed turns beyond the point at 




Spiral reversed bandage of the penis. 



88 



BANDAGING. 



which the recurrent turns terminated, and secured by one 
or two circular turns (Fig. 89). 

In applying this bandage to very short stumps result- 
ing from amputations at or near the shoulder- or hip-joint, 
after making the recurrent and spiral turns, it will be 
found necessary to carry the bandage, in the case of am- 
putations of the shoulder, across the chest to the opposite 
axilla and back, and apply several of these turns ; so in 
case of hip amputations it will be found best to finish the 
bandage with a few turns about the pelvis. 





Fig. 89. 














IE ^ 


^k_M 







Recurrent bandage of a stump. 

Bandage for Securing the Hands and Feet in the 
Lithotomy Position. — The hand of the patient should be 
brought down and made to grasp the outer side of the 
foot ; the initial extremity of the roller is fixed by two 
circular turns around the wrist and ankle, and the bandage 
is then passed around the foot and hand, and these turns 
are alternated with turns around the wrist and ankle until 
the hand and foot are firmly secured. The same proced- 
ure is adopted with the hand and foot of the opposite side 
(Fig. 90). 

Liebreich's Eye-bandage. — This bandage consists of 
a strip of flannel two and a half inches in width and from 
six to ten inches in length, to the extremities of which 



SPECIAL BANDAGES. 



89 



tapes are sewed. It may be applied transversely so as to 
cover both eyes, or obliquely so as to cover only one eye ; 
it is secured by the tapes carried around the head and tied 
over the forehead (Fig. 91). 

Use. — This bandage is used to hold compresses or 
dressings to the eye or eyes ; the elasticity of the flannel 
permits of its being applied so as to make a variable 
amount of pressure. 

Borsch's Eye -bandage. — This bandage is employed for 
holding a dressing to one eye, and consists in a strip of 
flannel, two or two and a half inches in width, which is 
passed around the head from the occiput and covers both 



Fig. 90. 



Fig. 91. 





Bandage for securing the hands 
and feet for lithotomy. 



Liebreich's eye-handage. 



eyes (Fig. 92). A narrow strip of flannel is attached to 
the posterior portion, which is carried over the head and 
passed under the horizontal strip in front of the eye which 
is to be left uncovered, and is then folded back so as to raise 
the horizontal strip from the eye, and secured (Fig. 93). 

Bandage of Scultetus. — This is a compound bandage, 
consisting of a number of pieces of muslin, and may be 



90 



BANDAGING. 



prepared from a two and a half or three inch roller by 
cutting off strips sufficiently long to encircle the part about 
one and one-third times. The strips are placed under the 
part in such a manner that the first piece shall be over- 
lapped by the second, the second by the third, and so on 
from below upward ; the pieces are then brought around 
the limb, and the extremities of the last piece are secured 
by pins (Fig. 94). This bandage was formerly much em- 
ployed in the treatment of compound fractures to secure 
dressings to the wound, and possessed the advantage that 



Fig. 92. 



Fig. 93. 





Application of Borsch's eye-bandage. 

when a single strip became soiled it could be removed with- 
out disturbing the whole dressing, the new strip to be in- 
troduced being pinned to the extremity of the soiled piece 
to be removed, and then being drawn through by its re- 
moval. This bandage will often be found convenient in 
applying dressings to cases of excision of the joints, where 
as little disturbance of the parts as possible is important 
in dressing the wound. When the strips are attached to 
each other by a thread passed through the centre of each 
strip, the bandage is known as Pott's bandage. It is 
applied and secured in the same manner, but it possesses 
no advantages over the bandage of Scultetus. 

Gauze Bandages. — Bandages may be prepared from 



SPECIAL BANDAGES. 



91 



gauze, the same material that is used for gauze dressings, 
and are now very extensively used in surgical practice. 
The gauze bandages are prepared by cutting or tearing 
the material into strips varying in width from two inches 
to three inches, and in length from five yards to eight 
yards ; these strips are then wound so as to form roller- 
bandages. Gauze bandages are sometimes employed in 
the dressing of fractures, but do not furnish as substantial 
a dressing as the ordinary muslin bandages. They, how- 

Fig. 94. 




Bandage of Scultetus. 

ever, constitute a soft and comfortable material for hold- 
ing dressings to wounds. They are applied in the same 
manner as the ordinary muslin roller, with the exception 
that in their application reverses are seldom required, as 
the open mesh of the bandage gives it considerable elas- 
ticity, so that the bandage can be made to adapt itself to 
the part without making reverses. Any of the ordinary 
bandages which have been previously described may be 
applied by means of the gauze bandages, such as those of 
the head, extremities, and trunk. 

Gauze Bandage of Head and Neck. — In applying dress- 
ings to wounds of the head and neck, it is advisable to 
cover in both the head and neck, and also to make a few 



92 



BANDAGING. 



turns over the upper part of the chest and around each 
shoulder, which prevents the turns of the bandage from 
slipping and holds the dressing in place, so that it cannot 
be disarranged by movements of the patient (Fig. 95). 

Gauze Bandage of Upper Extremity. — The initial ex- 
tremity of the bandage is secured by two or three turns 
around the wrist, and the bandage is then carried obliquely 
over the dorsum of the hand to the tip of the little finger, 

Fig. 95. 




Gauze bandage of head and neck. 



when a circular turn is made ; the hand is then covered in 
by circular turns. The region of the wrist is next covered 
by figure-of-eight turns and the bandage is carried up the 
forearm by circular turns. Figure-of-eight turns are made 
at the elbow and the bandage is continued with circular 
turns around the arm. No reverses need be made in ap- 
plying this bandage. 



SPECIAL BANDAGES. 



93 



Use. — This bandage is used for the same purposes as the 
spiral reversed bandage of the upper extremity. 

Gauze Bandage of Chest and Shoulder. — In applying this 
bandage, a gauze roller, three or four inches in width, is 
employed. The initial extremity of the bandage is secured 
around the lower portion of the chest by one or two turns 
and it is carried up to the axillary lines by circular turns ; 
at this point it is secured obliquely across the chest to the 
base of the neck and then behind the shoulder to the pos- 
terior portion of the axilla. From this point the turn is 

Fig. 96. 




Gauze bandage of chest and shoulder. 



carried through the axilla and over the shoulder and is con- 
ducted over the back of the chest to the posterior aspect 
of the opposite axilla, through which it passes to be carried 
over the anterior portion of the chest and shoulder to the 
opposite axilla. Then turns are repeated until a dressing 
of sufficient firmness is applied (Fig. 96). This bandage 
is used to secure dressings to the chest, axilla, and shoulder. 
Flannel Bandage. — These bandages are prepared from 
flannel, which is cut into strips from two to four inches in 
width and from five to seven yards in length. These 



94 



BANDAGING. 



strips are formed into rollers either by hand or by means 
of the bandage- winder. Flannel bandages, by reason of 
the elasticity which they possess, can be applied without 
reverses, and are used to make a moderate amount of elastic 
pressure. They are often employed in applying dressings 
to the head, especially after operations upon the eyes, and 
are generally applied as a primary roller before the appli- 
cation of plaster-of-Paris dressings, and may also be used 
in subacute joint-affections, both to protect the parts and 
to make a moderate amount of elastic pressure. 

Black Muslin Bandages. — From the fact that dark- 
colored bandages are less conspicuous than white ones, 

Fig. 97. 




Black muslin bandage of hand and arm. 

they are sometimes prepared from black or brown muslin. 
They are applied in the same manner as the ordinary mus- 
lin or gauze bandage. For this reason they may be used 
for bandages of the head, hand, or arm in patients w T ho 
are treated as walking cases, and who object to the con- 
spicuousness of a white bandage (Figs. 97 and 98). 

The Rubber Bandage. — This bandage, which was in- 
troduced to the profession by Dr. Martin, of Boston, is 
made from a strip of rubber-sheeting, from one inch to 
four inches in width and from three to five yards in 



SPECIAL BANDAGES. 



95 



length, which, for convenience of application, is rolled 
into a cylinder. It will be found a useful form of dress- 
ing where it is considered desirable to apply elastic press- 
ure to a part (Fig. 99). 

It may be employed in the treatment of varicose veins 
of the legs, in chronic ulcers of those parts where pressure 
is an important element in the treatment, and may be used 
as a substitute for strapping to secure this object. Its 
application has also been recommended in the treatment 

Fig. 98. 




Black muslin bandage of head. 



of swelled testicle in that stage of the affection in which 
pressure is indicated. 

For application to the leg, a rubber bandage two and a 
half inches in width and three yards in length is required. 

The initial extremity of the roller is fixed upon the foot 
near the toes and secured by a circular turn ; the foot is 
then covered in by spiral turns overlapping each other 
about two-thirds, and a fijnire-of-eiffht turn is made from 



d6 



11 A XT) AGING. 



the ankle to the instep. The bandage is then carried up 
the limb to the knee with spiral turns, where it is secured 
by two tapes sewed to the terminal extremity of the band- 
age, which are passed around the leg and tied. The band- 
;>ge need not be reversed, as its elasticity allows it to con- 
form to the shape of the limb. Care should be taken not 
to apply the turns with too much firmness ; the bandage 
should be stretched very slightly ; if this precaution is 

Fig. 99. 




Martin's rubber bandage. 



not taken, it soon becomes uncomfortable to the patient. 
A patient using one of these bandages will soon learn to 
apply it himself, making just the requisite amount of ten- 
sion to secure its holding its place, and to insure a com- 
fortable degree of pressure upon the part. A well-fitting 
stocking may be placed upon the limb before the bandage 
is applied, or it may be applied directly to the skin. 

The bandage should be removed at night when the 
patient goes to bed and hung up to dry, as its inner sur- 
face becomes moist from the secretions from the skin ; it 
should be reapplied as soon as the patient rises in the 
morning. 

In using it in the treatment of ulcers of the leg no oint- 
ment should be applied to the ulcer, as oily dressings soon 
destroy the rubber ; applications may be made to the ulcer 
by means of dry powders, such as oxide of zinc, iodoform, 
or aristol, before the bandage is applied. 

In the treatment of swelled testicle the bandage is ap- 
plied to the testicle by means of recurrent turns not too 



SPECIAL BANDAGES. 



97 



firmly made, and secured in place by spiral turns, until the 
whole surface of the organ is covered in ; the end of the 
bandage is secured with tapes tied around the root of the 
scrotum. The same precaution to apply the bandage so 
as to make only moderate pressure should also be observed 
here. 

Elastic-webbing Bandage. — This bandage, which is 
woven from threads of rubber covered with cotton or silk, 
has recently been introduced, and possesses all the advan- 
tages of the rubber bandage as regards elasticity, and has 
the additional advantage that air can circulate through the 
meshes of the bandage and moisture can evaporate from 
the surface covered by the bandage, so that the skin cov- 
ered by it does not become bathed in perspiration, as is 
the case with the rubber bandage. It is applied in the 
same manner and for the same purposes as the rubber 

Fig. 100. 




Elastic webbing bandage applied to leg. 



bandage (Fig. 100). The patient soon learns to apply it 
himself, so as to make the requisite amount of pressure. 
In the treatment of varicose veins and oedema of the legs 
we have found it a most satisfactory dressing. 



98 BANDAGING. 



FIXED DRESSINGS, OR HARDENING BANDAGES. 

For the application of these dressings a variety of 
substances are used which are incorporated in the meshes 
of some fabric, such as crinoline or cheese-cloth, or painted 
over its surface to give fixity or solidity to the bandage. 

The materials most commonly used in the preparation 
of fixed dressings are plaster-of-Paris, starch, silicate of 
sodium or potassium, and paraffin. 

Plaster-of-Paris Dressings. 

The plaster-of- Paris used for the application of surgical 
dressings should be of the same quality as that which 
dental surgeons employ in taking casts for teeth — that is, 
the extra-calcined variety. If moist or of inferior quality, 
it will not set rapidly or firmly, and will fail to give suffi- 
cient fixation to the dressing. 

Methods of Applying Plaster-of-Paris Dressings.— 
The plaster-of-Paris dressing may be applied in several 
ways, either by covering the part to be enclosed with some 
loose fabric, and rubbing the moist plaster into it, alter- 
nating the layers of the fabric with layers of moist plaster, 
or it may be applied by means of a roller which has been 
prepared by incorporating plaster-of-Paris in its meshes. 

It may also be applied in the form of the Bavarian 
dressing (page 105), or in the form of moulded plaster-of- 
Paris splints (page 107). 

To apply a plaster-of-Paris dressing according to the first 
method, the part to be enclosed — the leg, for instance — 
should first be covered by a neatly applied flannel bandage, 
or a muslin bandage which has been shrunken by being 
washed ; new muslin is not satisfactory as a primary appli- 
cation to a limb in applying a plaster-of-Paris dressing, as 
the moisture from the plaster wets it and causes it to 
shrink, so that it may exert injurious pressure after the 
bandage becomes dry. 

The limb having been covered by the bandage, and any 



FIXED DRESSINGS, OR HARDENING BANDAGES. 99 

bony prominences, such as the malleoli, having been 
padded with small wads of cotton to prevent undue 
pressure upon them, the part is next covered by a layer 
of turns of a crinoline bandage or by strips of cheese- 
cloth or any other loose material. A small quantity of 
plaster-of-Paris is next mixed with water until it has the 
consistence of thick cream, when it is smeared evenly 
over the whole surface of the previously applied bandage. 
Another layer of the bandage or of strips is next applied, 
and the plaster is smeared over this in the same manner, 
and so alternate layers of plaster-of-Paris and bandage are 
applied until a casing of the desired thickness is obtained. 
If plaster-of-Paris of the quality previously described be 
used, it will set or become hard in a few minutes. 

The most convenient method of applying the plaster- 
of-Paris dressing is that introduced by the late Professor 
Sayre, which consists in the use of bandages which have 
been previously prepared with plaster-of-Paris ; these 
are moistened and applied while moist to the part to be 
encased. 

Preparation of Plaster-of-Paris Bandages. — These 
bandages are prepared by taking cheese-cloth, mosquito- 
netting, or crinoline, which latter is by far the best 
fabric, and cutting or tearing it into strips two and a half 
to three inches in width and five yards in length. These 
are laid on a table, and plaster-of-Paris of the quality 
before mentioned is dusted over them and rubbed into the 
meshes of the fabric ; the material when impregnated with 
plaster is loosely rolled into a cylinder, and these band- 
ages when prepared should be placed in air-tight jars or 
tin cans until required. 

Bandages thus prepared, which have been exposed to 
the air or have been kept for a long time, are not apt to 
set well when applied ; but if such bandages are placed 
in a hot oven and baked for half an hour before being 
used, they will be found to set as satisfactorily as those 
freshly prepared. 

These bandages may be prepared by a machine made 
for this purpose; but I do not think that they are apt to 
haye the plaster as evenly distributed through them, and, 



100 



BANDAGING. 



therefore, are not as satisfactory as those prepared by 
hand. 

Application of the Plaster-of-Paris Bandage. — Before 
applying this dressing, the part to be encased — the leg, for 
instance — should be covered by a flannel roller, the bony 
prominences being protected by pads of cotton, or a 
closely fitting stocking may be applied to the part. Cotton 
wadding cut into strips of the desired width and formed 
into a roller may be used instead of the flannel roller. 

The bandage should be dipped in warm water and kept 
completely immersed for a few minutes ; it should then be 
squeezed with the hand, and as soon as bubbles of air 
cease to escape it is a sign that it is thoroughly soaked 

Fig. 101. 




Leg encased in plaster-of- Paris dressing. 



and is ready for application. On removing it from the 
water the excess of water should be squeezed out by the 
hand, and the bandage should then be applied evenly to 
the limb with just sufficient firmness to make it fit the 
part nicely, and as few reverses as possible should be 
made. A sufficient number of bandages are applied to 
make a dressing as firm as may be required ; three rollers 
of the above dimensions are usually ample for a dressing 
for the leg, and when the last roller has been applied dry 
plaster should be moistened with water until it has the 
consistency of thick cream, and rubbed evenly over the 



FIXED DRESSINGS, OR HARDENING BANDAGES. 101 

surface of the bandage to give it a finish (Fig. 101). If a 
good quality of plaster has been used, the bandage should 
be quite firm in from ten to fifteen minutes, but the patient 
should not for a few hours be allowed to bear any weight 
upon the bandage. 

An equally firm dressing may be applied with the use 
of a less number of bandages, if the surgeon rubs over 
the surface of each layer of bandage applied a little moist 
plaster, then applying another layer and repeating the 
procedure ; finishing the dressing by an external coating 
of moist plaster, as above described. 

In applying these dressings a fewer number of band- 
ages will be required if narrow strips of tin, zinc, or 
binders' board are incorporated in the layers of the band- 
age, which increase the strength of the dressing. 

Application of the Plaster-of-Paris Bandage to the 
Thigh and Pelvis. — Where it is desirable to apply a 

Fk;. 102. 




Pelvic supporter. 

plaster-of-Paris bandage to the thigh, and at the same 
time fix the hip-joint by including the pelvis in the band- 
age, the use of a pelvic supporter (Fig. 102) is most satis- 
factory. The patient is placed upon the supporter so that 
the lumbar spine rests upon the body of the supporter, 
while the pelvis rests upon the metal shelf which extends 
from it, as seen in Fig. 103. The limb is extended and 
held in the required position, and the plaster bandage is 
applied to the thigh, and is also carried around the pelvis 
and passed over the metal shelf upon which the pelvis 



102 



BANDAGING. 



rests. When the bandage has become firm, the supporter 
is removed by slipping it upward. 

Fig. 103. 




Position of patient upon pelvic supporter. 

Interrupted Plaster-of-Paris Dressing. — This form 
of plaster-of-Paris dressing is applied by first placing a 
short iron rod under the extremity, opposite to and extend- 
ing some distance above and below the point at which the 



Fig. 104. 




Interrupted plaster-of-Paris dressing. (Stimson. 



dressing is to be interrupted ; this is fixed by a few turns 
of the plaster bandage above and below the portion of 
the limb which is to be left exposed ; stout wire is next 
bent into loops, the extremities of which are incorporated 
in the subsequent turns of the plaster bandage ; three 
loops thus placed in addition to the posterior iron bar 



FIXED DRESSINGS, OR HARDENING BANDAGES. 103 

will usually make the dressing sufficiently firm (Fig. 104). 
A number of turns of the bandage are applied to fix the 
metal loops firmly, and the limb is held in the desired 
position until the plaster has set. 

Application of the Plaster-of-Paris Jacket. — The 
patient's body should be covered with a soft, closely 
fitting woven shirt without arms, but with shoulder-straps 
to hold it in position, or an ordinary woven undershirt may 
be employed ; one or two folded towels, or a pad of cotton 
wrapped in a towel, are next placed over the abdomen 
between the shirt and the skin — this was called, by Pro- 
fessor Say re, the dinner pad, and is intended to leave space 
for distention of the abdomen after eating. Small pads of 
raw cotton may also be placed over the anterior iliac spines, 
and, in the case of females, a pad of cotton wrapped in a 
handkerchief may be placed over each mammary gland. 

The patient should next be suspended by the apparatus, 
consisting of a collar and arm-pieces attached to a cross- 
bar (Fig. 105), which is attached by a cord and pulley to a 
tripod. If this apparatus is not at hand, a very satisfac- 
tory substitute may be made by folding two towels into 
cravats and tying together the ends, so as to make two 
loops, one of which is placed in each axilla ; a bar of wood 
two and a half feet in length is next taken, and the loops 
are secured to the ends of this by stout cords or handker- 
chiefs ; a Barton's bandage is next applied to the head, and 
a strip of bandage is passed under the turns which cross 
the vertex and is secured to the middle of the cross-bar. 
The bar is next suspended by a cord passed through a 
pulley or ring, which may be attached to the top frame of 
a door if the ordinary tripod cannot be obtained. 

The patient should be raised slowly by the apparatus 
until the toes only are in contact with the floor, and the ex- 
tension should not be carried to the point which makes it 
uncomfortable to the patient (Fig. 106). The shirt should 
be drawn downward over the hips by an assistant and held 
in place until a few turns of the bandage have been applied. 

The plaster-bandage having been soaked and squeezed, 
a turn should be made around the body above the pelvis, 
and it should then be carried downward below the iliac 



104 



BANDAGING. 



spines, and from this point made to ascend gradually 
by spiral turns until it reaches the axillary line. The 
turns should be applied smoothly and not too tightly. 
After two or three layers of turns have been applied, the 
surgeon may rub some moist plaster upon their surface if 



Fig. 105. 



Fig. 106. 




Suspensory apparatus. 



Patient suspended for application of 
plaster jacket. 



he desires to use fewer bandages. These turns are repeated 
until a bandage of the desired thickness is applied, and the 
surface of the dressing may be finished by rubbing it over 
with moistened plaster. This jacket for a child will gen- 
erally require the use of three or four bandages of the 
dimensions given ; for an adult, from six to eight bandages. 



FIXED DRESSINGS, OR HARDENING BANDAGES. 105 



The patient should be kept suspended until the bandage 
has set, usually from ten to fifteen minutes, and then should 
be lifted carefully so as not to bend the spine, and placed 
on his back upon a mattress, until the dressing becomes 
perfectly hardened. The dinner pad and mammary pads, 
if they have been used, should next be removed. In 
applying this dressing, strips of zinc or tin may be placed 
between the layers of bandage if it is desired to give more 
strength to the jacket. 

Application of the Jury-mast by Means of Plaster- 
of-Paris. — In disease of the spine involving the cervical 
or upper dorsal region the ordinary plaster-of- Paris jacket 
is not satisfactory, and in such 
cases the "jury-mast " is employed 
in connection with the plaster 
jacket. In applying the "jury- 
mast," the same steps are taken in 
the preparation of the patient as 
in applying the plaster-of-Paris 
jacket, with the exception of ex- 
tension, which need not be used. 

After three or four layers of the 
plaster-bandage have been applied 
to the body, an apparatus made of 
two bars of metal having two per- 
forated strips of zinc attached to 
them a few inches apart, which 
partly encircle the body, is applied 
and held in position by turns of 
the plaster-bandage. The perpen- 
dicular bars have at their upper 
part a slot, into which the lower 
end of the "jury-mast" fits, and 
is secured by a screw ; to the upper 
part of this is attached a movable 

cross-bar, to which are fastened the straps of the collar 
from which the head is suspended (Fig. 107). 

The Bavarian Dressing". — To apply this dressing, 
which is sometimes employed in the treatment of fractures 




Head-support and jury-mast. 



106 



BANDAGING. 



of the extremities, take two pieces of Canton flannel the 
length of the part to be enclosed, and more than wide 
enough to envelop its circumference. In applying it to 
the leg, these pieces should be cut so as to correspond to 
the outline of the leg and posterior portion of the foot. 
These pieces should be placed one over the other and 
sewed together in the middle line, the seam corresponding 
to the back of the leg. This dressing is then placed under 
the foot and leg, and the inner layer of flannel is brought 
up in front of the leg and over the dorsum of the foot, and 
made fast with pins or a few stitches (Fig. 108). Plaster- 

Fig. 108. 




Bavarian dressing. 



of-Paris is next mixed with water to form a paste, which 
is rubbed thickly and evenly over the flannel next the 
limb until a sufficient thickness is obtained ; the outer 
layer of flannel is then brought up about the leg and 
moulded to its surface by the hands. A loosely applied 
roller may be used to hold the dressing in place until the 
plaster has set. 

When it is necessary to inspect the parts, the turns of 
the bandage are cut, and upon separating the layers of 
flannel the two halves can be turned aside, the seam at the 
back acting as a hinge. Upon reapplying the splints to 



FIXED DRESSINGS, OR HARDENING BANDAGES. 107 

the leg they may be retained in position by a roller or by 
one or two strips of bandage. 

Moulded Plaster Splints. — It is sometimes found diffi- 
cult to apply the ordinary plaster dressings to parts irreg- 
ular in shape, and at the same time to have a splint which 
can be removed with ease. To accomplish this purpose, 
moulded splints of plaster may be made by cutting a 
paper pattern of the part to be covered in, and then cutting 
pieces of crinoline to conform to this pattern ; eight or ten 
pieces will usually form a splint of sufficient thickness. 
One of these pieces of crinoline is laid upon a table and 
dry plaster is rubbed into its meshes ; another is laid 
upon this and plaster is applied to it in the same way, 
and so on until all the pieces have been placed in posi- 
tion, one over the other, with plaster rubbed well into 
the meshes. The dressing is then folded up and dipped 
into water, squeezed out, and moulded to the part and held 
in position, until it sets, by the turns of a bandage. The 
edges should overlap slightly, and in applying it a strip of 
waxed paper may be placed under the overlapping edge to 
prevent its adhesion to the dressing below, and thus facili- 
tate its removal. Splints prepared in this way can be re- 
moved with ease, and are often of service in cases where 
it is desirable to inspect the parts frequently. I have em- 
ployed with advantage such splints in making fixation of 
the hip-joint in cases of coxalgia, and also for the same 
purpose in diseases of other joints. The splints upon 
being reapplied are secured by a few strips of adhesive 
plaster or by a roller-bandage. 

Trapping" Plaster-of-Paris Bandages. — In applying 
the plaster-of- Paris dressing to a part where there is a 
wound which is covered by the plaster-bandage, it is well 
to make some provision whereby the plaster dressing over 
the site of the wound may be cut away, making a trap or 
window through which the wound may be inspected, or 
dressed if necessary (Fig. 109). To accomplish this, be- 
fore applying the plaster-bandage, a compress of lint or 
gauze or a small pasteboard box should be placed over 
the wound, which, when the dressing is completed, forms 



108 



BANDAGING. 



a projection on its surface, indicating the position of the 
wound, and also allows the surgeon to cut away the dress- 
ing without injuring the skin below. These traps may be 
cut out after the bandage has partially set, or after it has 
become hard. In applying the plaster-of-Paris dressing 
in cases of compound fracture, I always make provision 
for trapping of the bandage if it should become necessary, 
although in the vast majority of cases if the wound re- 
main aseptic it does not have to be done. 

Fig. 109? 




Plaster-of-Paris bandage trapped. 



Removing Plaster-of-Paris from the Hands. — One 

objection to the use of plaster-of-Paris dressings is the 
difficulty of removing it from the hands of the surgeon, 
and the harsh condition in which the skin is left after its 
removal. If, however, the hands are washed in a solu- 
tion of carbonate of sodium — a tablespoonful to a basin 
of water — the plaster will readily be removed and the 
skin will be left in a soft and comfortable condition. Rub- 
bing the hands with glycerine, moist brown sugar or corn- 
meal accomplishes the same object. 



FIXED DRESSINGS, OR HARDENING BANDAGES. 109 

Removal of the Plaster-of-Paris Bandage. — The 

removal of the plaster-bandage is sometimes a matter of 
difficulty, particularly, in the case of fractures, if it has to 
be removed before the fragments below it are consoli- 
dated, as it may disarrange them and cause the patient 
pain if it is not accomplished without much force. 

When the bandage is applied to get a cast of a part, or 
in the treatment of fractures where it may be necessary to 
remove the bandage in a few days to inspect the parts, a 
strip of sheet-lead one-half of an inch in width is first 
placed over the flannel bandage and is allowed to project 
at each. end beyond the dressing; the plaster can then be 
readily cut through upon the strip of lead with a knife 
without injury to the parts below (Fig. 110). As soon as the 

Fig. 110. 




Cutting plaster-bandage upon lead strip. 



bandage has become firm, the lead strip is removed by trac- 
tion upon one end of it ; and, if the bandage has been entirely 
divided, it can be removed at any time without difficulty. 
In applying plaster dressings to the extremities, even 
if their removal is not likely to be immediately required, 
I usually employ the lead strip, cutting the bandage upon 
it, but leaving three or four bridges of undivided band- 



110 



BANDAGING. 



age, which can easily be divided when the removal of the 
bandage is finally required. 

Plaster-bandages may also be removed by means of a 
saw devised for this purpose (Fig. Ill); by Gigli's wire 
saw drawn under the bandage by a string, which cuts 
rapidly and does not endanger the skin ; by strong cutting- 




Hunter's saw for removing plaster bandages. 

shears of various kinds (Fig. 112) ; or a line may be painted 
over the dressing with hydrochloric acid or vinegar, which 
softens the plaster, so that it can readily be cut through 
with a knife. The incision of the bandage upon the lead 
strip or the use of the saw or shears is, I think, most 
satisfactory in removing these dressings. They should 

Fig. 112. 




Shears for cutting plaster-bandages. 

be used carefully, as the final layers of the bandage are 
divided, to avoid wounding the skin. 

Uses of Plaster-of-Paris Dressings. — These dressings 
are employed to secure fixation as primary or secondary 
dressings in the treatment of fractures, and in the ambu- 
lant treatment of fractures, and for a like purpose in 
injuries and diseases of the joints. They are also largely 
employed in the treatment of diseases and deformities of 
the spinal column, and will be found most satisfactory 
applications after osteotomy and tenotomy, to secure im- 
mobility and to hold the parts in their corrected positions ; 



FIXED DRESSINGS, OR HARDENING BANDAGES. Ill 

when employed in the dressing of cases after tenotomy, 
they are generally used for a few weeks until the appro- 
priate mechanical apparatus is applied. 

The Starched Bandage. — To apply this bandage, 
starch is first mixed with cold water until a thin, creamy 
mixture results, and this is heated until it is converted into 
a clear mucilaginous liquid. The part to be dressed is first 
covered with a flannel roller, and over this a few layers 
of a cheese-cloth or crinoline bandage, which has been 
shrunken, are applied ; the starch is then smeared or 
rubbed with the hand evenly into the meshes of the mate- 
rial, and the part is again covered with a layer of turns 
of the bandage, and the starch is again applied ; this 
manipulation is continued until a dressing of the desired 
thickness is produced. Strips of pasteboard may be 
applied between the layers of the bandage, to give addi- 
tional strength to the dressing, if desired. 

It requires from twenty-four to thirty-six hours for the 
starched bandage to become dry and thoroughly set. It 
may be removed in the same way in which the plaster-of- 
Paris dressing is removed. 

Use. — Before the introduction of the plaster-of-Paris 
dressing, it was frequently employed in the treatment of 
fractures, and in injuries and diseases of the joints. It 
may be used in such cases, but possesses no advantage 
over the plaster-of-Paris dressing, and has the disadvan- 
tage of setting much less promptly. 

Silicate of Potassium or Sodium Bandage. — In 
applying this bandage, after a flannel roller and several 
layers of a cheese-cloth or crinoline bandage have been 
applied to the part, the surface of the latter is coated with 
silieate of sodium or potassium applied by means of a 
brush, then a second layer of bandage is applied and 
treated in the same manner, and this manipulation is con- 
tinued until a bandage of the desired thickness is pro- 
duced. This dressing may also be applied by soaking 
loosely wound rollers of crinoline in silicate of potassium 
or sodium and applying them to the part as the plaster-of- 
Paris bandage is applied. It requires twenty-four hours 



i 



112 BANDAGING. 

for this dressing to become firm. As it is irksome for a 
patient to keep a part quiet while the silicate bandage is 
becoming firm, I often cover it as soon as applied with a 
layer of tissue-paper, and apply over it a light plaster-of- 
Paris bandage, which sets in a few minutes ; this is removed 
at the end of twenty-four hours, when the silicate bandage is 
usually firm. In removing the silicate bandage, it may first 
be softened by soaking it in warm water, and then it can read- 
ily be cut with scissors, or it may be cut with bandage-shears. 

In applying either the starched bandage or the silicate of 
potassium bandage, care should be taken to use cheese-cloth 
or crinoline which has been shrunken by being moistened 
and allowed to dry before being employed ; otherwise, dan- 
gerous compression of the part may occur if the bandage 
has been firmly applied and shrinks after its application. 

The Paraffin-bandage. — Paraffin, which melts at from 
105° to 120° F., is used in the application of this band- 
age. The limb being covered by a flannel roller, a vessel 
containing paraffin is placed in a basin of boiling water. 
As the roller, which may be either of flannel, cheese-cloth, 
or crinoline, is unwound, it is passed through the melted 
paraffin and applied to the part, and the turns are repeated 
until a dressing of sufficient thickness results, when the 
surface may be brushed over with melted paraffin. This 
dressing sets very rapidly, being quite firm in from five to 
ten minutes. 

Moulded Splints. 

Raw-hide or Leather Splints. — In moulding raw- 
hide or leather splints, it is necessary, first, to apply a 
plaster-of-Paris bandage to the part to which the raw- 
hide splint is to be fitted ; and as soon as the plaster 
has set, it is removed, and a solid plaster cast is next 
made by pouring liquid plaster-of-Paris into this mould. 
When this has become dry, a piece of raw-hide, which 
has been soaked for a time in warm water, is moulded 
to the cast and held firmly in contact with it by tacks 
or a bandage until it has become perfectly dry. It is 
then removed, and its surface is covered with several 
coats of shellac, to prevent its absorbing moisture from 



FIXED DRESSINGS, OR HARDENING BANDAGES. 113 



Fig. 113. 



the skin when applied, and changing its shape. Eyelets 
or hooks are fastened to the edges of the splint, through 
which tapes are passed to secure it in place. 

Made in this manner, raw-hide splints fit the part very 
accurately, and constitute a very satisfactory dressing for 
cases of joint-disease, and in the form of leather jackets 
are often employed in the treatment of disease of the spine 
in place of the plaster-of-Paris jacket (Fig. 113). 

In the treatment of high dorsal or cervical caries a 
leather splint in two sections, which 
rests upon the shoulders and sup- 
ports the head, is often used with 
good results (Fig. 114). 

Binders' Board or Pasteboard 
Splints. — This material, which can 
be obtained in sheets of different 
thicknesses, is frequently employed 
for the manufacture of splints. In 
moulding these splints, a portion of 
the board of the requisite size and 

Fig. 1 1 4. 





Leather jacket with jury- 
mast. 



Leather splint for cervical caries. 
(Owen.) 



thickness is dipped in boiling water for a short time, and 
when it has become softened it is removed and allowed to 
cool ; a thick layer of cotton-batting is next applied over 
it, and it is then moulded to the part and held firmly in 



114 BANDAGING. 

place by the turns of a roller-bandage; in a few hours it 
becomes dry and hard. 

This material, from its cheapness and the ease with which 
it is obtained, is frequently employed to mould splints in 
the treatment of fractures. Moulded splints of this kind 
on account of the ease of their application and removal 
are often useful in the temporary treatment of compound 
fractures and excision of joints to fix the ends of the bones. 
In such cases it is often desirable to inspect and dress the 
wounds until healing has occurred, when a fixed dressing 
of plaster-of-Paris may be employed. 

Porous Felt Splints. — This material is also employed 
for the manufacture of splints, and is applied by dipping 
the material in hot water and then moulding it to the part 
and securing it by a bandage ; as it dries, it becomes hard. 

Hatters'-felt Splints. — Hatters'-felt may also be em- 
ployed for the manufacture of splints or dressings. It is 
softened by dipping it in boiling water or heating it in the 
flame of an alcohol lamp, and when soft and pliable it is 
moulded to the part, and as it cools it again becomes hard. 
These splints are employed for the same purpose as those 
made of plaster-of-Paris, leather, or pasteboard. 



P -A. E T II. 
M I X R SUE G E R Y 



Antiseptic and Aseptic Surgical Dressings. — This 
subject is considered on page 308. 

MATERIALS USED IN SURGICAL DRESSINGS. 

Lint. — This material is employed in surgical dressings, 
and is of two varieties : the domestic lint, which consists 
of pieces of old linen or muslin which have been thoroughly 
washed or boiled and then dried, or the surgical lint, which 
resemble Canton flannel in appearance ; the latter is the 
best material, as it has a greater absorbing capacity. 

Lint is use.i as a material on which unctuous prepara- 
- are spread in the dressing of wounds, and is em- 
ployed also as a material for sa:u rating with the various 
solutions which are used in wet di 36 gs, such as lead- 
water and laudanum : the lint, after being saturated with 
- <x»vered with nil i led silk when 

applied, to prevent too rapid evaporation of the solution. 
It is also one of the best materials from which to construct 
the compresses employed in the treatment of fractu : 

Paper-lint. — This is made from old ra^s or wood-pulp. 

- _reat absorbing power for fluids, and may be u- 

a substitute for surgical lint in the application of wet 
ssings to surfaces when the skin is unbroken. 
Oakum. — This material, made from old tarred rope, 

- formerly much employed in the d: ae _ inds. 
before the introduction of the antiseptic meth 
wound treatment. Fn»m its elasticity it is found to be 
an excellent material for padding splints or other si: _ 
appliances. It is employed also in the form of pa 
place under patients to relieve portions of the body from 
pressure, or to absorb discharges which soak through the 

::: 



116 MINOR SURGERY. 

dressings. A mass of oakum which has been Ay ell teased 
out and wrapped in a towel forms an excellent pillow on 
which to support a stump. 

Cotton. — Cotton is now employed in surgical dressings 
principally as a material to pad splints or to relieve 
salient parts of the skeleton from pressure in the applica- 
tion of splints or bandages ; for instance, in the applica- 
tion of the plaster-of- Paris bandage, the bony prominences 
are generally covered with small masses of cotton. It pos- 
sesses but little absorbent power unless used in the form 
of absorbent cotton, and is not much employed in surgical 
dressings except for the purposes mentioned above. 

Absorbent Cotton. — This material is prepared from 
ordinary cotton, which is boiled with a strong alkali to 
remove the oily matter which it contains. When so pre- 
pared, it absorbs liquids freely, and by reason of its great 
absorbing capacity it is employed largely in surgical dress- 
ings. A small mass of sterilized absorbent cotton wrapped 
upon the end of a probe is now generally employed to 
make applications to wounds, and has taken the place of 
the sponge or brush which formerly was employed for this 
purpose. On account of its cheapness, after one applica- 
tion it can be thrown away and a new piece used, and thus 
the danger of carrying infection from one wound to an- 
other by the applicator is abolished. It is largely em- 
ployed in gynecological practice for making applications 
to the female genital organs. 

Wood-wool. — Wood-wool made from Ayood-pulp, such 
as is employed in the manufacture of paper, is also fur- 
nished in the shape of lint, sponges, and pads, and may be 
used for the same purposes as the ordinary surgical lint. 

Oiled Silk or Muslin. — These materials are employed 
as an external covering for moist dressings to prevent 
rapid evaporation from the dressings ; they form excellent 
materials for this purpose, but as they are quite expensive 
their use is limited. 

Waxed or Paraffin-paper. — This dressing is prepared 
by passing sheets of tissue-paper through melted wax or 
paraffin, and then allowing them to dry. Paper thus treated 



TAMPON. 117 

forms an excellent and cheap substitute for oiled silk or 
muslin, and may be employed for the same purpose for 
which the latter materials are used. 

Rubber-tissue. — This material, which is prepared by 
rubber manufacturers, consists of rubber run out into very 
thin sheets. It has a glazed surface, is very pliable, and 
at the same time strong, forming, therefore, a cheap and 
satisfactory substitute for oiled silk, and is employed for 
the same purposes. A tent made of rubber-tissue may be 
used as a drain for wounds ; it is also used in making the 
cigarette drain. 

Parchment-paper. — This paper is prepared so as to 
render it water-proof; it is employed in surgical dressings 
for the same purposes as oiled silk and rubber-tissue. 

Compresses. — Compresses are prepared by folding pieces 
of lint, muslin, linen, or gauze upon themselves, so as to 
form firm masses of variable size ; oakum or cotton may 
also be used to form compresses. Compresses are em- 
ployed to make pressure over localized portions of the 
body, as in the treatment of fractures, or to make press- 
ure upon vessels for the control of hemorrhage. 

Tampon. — A tampon is a form of compress which is 
employed in cavities to make pressure, to control hemor- 
rhage, or to apply various solutions or powders to the 
surface of the cavity. Tampons used to control hemor- 
rhage are generally made of strips of bichloride, iodo- 
form or sterilized gauze. In applying these, the strips of 
gauze are packed into the cavity, and when the latter is 
full a compress is applied superficially and held in place 
by a bandage. The application of a tampon to the vagina 
is a favorite method of controlling uterine hemorrhage. 

Glycerin Tampon. — This is made by pouring half an 
ounce of glycerin on a piece of cotton or wool, and then 
turning up the ends and securing them by a string, one 
end of which is allowed to remain long enough to hang 
from the vagina, to facilitate its removal ; it is a favorite 
application to the os uteri. 

Tent. — This consists of a small portion of lint, oakum, 
muslin, or sterilized or antiseptic gauze rolled into a coni- 



118 



MINOR SURGERY. 



cal shape, which is employed to keep wounds open and to 
facilitate the escape of discharges. 

Retractors. — Retractors are made by taking a piece of 
muslin four inches wide and twelve to eighteen inches in 
length, and splitting it as far as the centre, thus making a 
two-tailed retractor (Fig. 115). A three-tailed retractor is 
made in the same way, except that the muslin is slit twice 
instead of once (Fig. 116). Retractors are used to retract 
the soft parts in amputations, to prevent their injury by 






Fig. 115. 



Fig. 116. 




11 


Pljiiii;!;:;; ' 


" 



Two-tailed retractor. 



Three-tailed retractor. 



the saw in the division of the bones. When one bone 
is sawed a two-tailed retractor is used, and when two 
bones are sawed a three-tailed retractor is employed. 

Plasters. — The varieties of plaster which are most 
commonly employed in surgical dressings are adhesive or 
resin plaster, isinglass plaster, and rubber adhesive plaster. 



PLASTERS. 119 

Before using any of these plasters upon parts which are 
covered by hairs, the latter should be removed by shaving, 
otherwise traction upon them, if the plaster be used for 
the purpose of extension, will cause the patient discom- 
fort, and unnecessary pain will also be inflicted at the time 
of its removal. 

Resin Plaster. — This plaster, which is machine-spread, 
is employed frequently in surgical dressings ; the spread 
surface is covered with a layer of tissue-paper, which should 
be removed before it is used ; it is cut into strips of the 
required width and length, and the strips should be cut 
lengthwise from the roll of plaster, as the cloth upon which 
it is spread stretches more transversely than in a longitudi- 
nal direction. When heated and applied to the surface it 
holds firmly ; it is prepared for application by applying the 
unspread side to a vessel containing hot water, or it may 
be passed rapidly through the flame of an alcohol lamp. 

This is the variety of plaster which is generally used in 
making the extension-apparatus for the treatment of fract- 
ures, for strapping the chest in fractures of the ribs and 
sternum, for strapping the pelvis in cases of fractures of 
the pelvic bones, and for strapping the breast, the testicle, 
ulcers, or joints. 

Swans'-down Plaster. — This plaster is much the same as 
resin plaster, but is spread upon a heavier material, and 
is an excellent plaster to use for an extension-apparatus, 
where it is to be worn for a long time. 

Rubber Adhesive Plaster. — This plaster is made by 
spreading a preparation of India-rubber on muslin, and 
has the advantage over the ordinary resin plaster that it 
adheres without the application of heat. It is employed 
for the same purpose as resin plaster, but when applied 
continuously to the skin it is apt to produce a certain 
amount of irritation, and for this reason when it is to be 
applied for some time, as in the case of an extension- 
apparatus, it is not so comfortable a dressing as that 
made from resin plaster. 

Zinc Oxide Adhesive Plaster. — This plaster is prepared by 
incorporating with rubber adhesive plaster oxide of zinc. 



120 MINOR SURGERY. 

It is equally as adhesive as the rubber plaster, and pos- 
sesses the advantage that it is not apt to produce irritation 
of the skin. It is used for the same purposes as the 
rubber adhesive plaster. 

Isinglass Plaster. — This plaster is made by spreading a 
solution of isinglass upon silk or muslin, and it has been 
found a most useful dressing in the treatment of superficial 
wounds. It is caused to adhere to the surface by moisten- 
ing it, and when used in the treatment of wounds it should 
be moistened with an antiseptic solution. The best variety 
is spread on muslin, and when properly applied adheres as 
firmly and possesses as much strength as the ordinary resin 
plaster. 

Soap Plaster. — Soap plaster for surgical purposes is 
prepared by spreading emplastrum saponis upon kid or 
chamois skin. It is not employed for the same purposes 
as the resin or rubber plaster, as it has little adhesive 
power, and is used simply to give support to parts or to 
protect salient portions of the skeleton from pressure. It 
is found to be a most useful dressing when applied over 
the sacrum in cases of threatened bedsores, and may be 
applied for the same purpose to other parts of the body 
where pressure-sores are apt to occur. 

In the treatment of sprains of joints, a well-moulded 
soap-plaster splint secured by a bandage will often be 
found a most efficient dressing, and in the treatment of 
fractures the comfort of the patient is often materially 
increased by applying small pieces of soap plaster over 
the bony prominences, upon which the splints, even when 
well padded, are apt to make an undue amount of pressure. 



STRAPPING. 

This consists in applying pressure to parts by means 
of strips of plaster firmly applied ; it is a procedure often 
employed in surgical practice. 

Strapping the Testicle. — In strapping the testicle, 
strips of resin plaster are usually employed ; a dozen or 






STRAPPING OF THE CHEST. 121 

more strips one-half an inch wide and twelve inches in 
length will be required. 

The scrotum should first be washed and shaved, and the 
surgeon next draws the skin over the aifected organ tense 
by passing the thumb and finger around the scrotum at 
its upper portion, making circular constriction ; a strip of 
muslin is passed in a circular manner around the skin of 
the scrotum above the organ, and is tightly drawn and 
secured by passing around it a strap of plaster which has 
been heated ; this isolates the part and prevents the other 
straps from slipping. Straps are now applied in a longi- 
tudinal direction, the first strap being fastened to the 
circular strap and carried over the most prominent part 
of the testicle, and then carried back to the circular strap 

Fig. 117. 





Strapping the testicle. (Smith.) 

and fastened. A number of these straps are applied in an 
imbricated manner until the skin is covered (Fig. 117), 
and the dressing is completed by passing transverse straps 
around the testicle from its lowest portion to the circular 
strap ; care should be taken to see that no portion of the 
skin is left uncovered. 

Strapping the testicle is employed with advantage in the 
subacute stage of orchitis or epididymitis ; as the swelling 
of the testicle diminishes the straps become loose, and the 
part will require re-strapping. It will also be found a 
useful means of applying pressure to the scrotum after the 
injection-treatment of hydrocele. 

Strapping of the Chest. — To strap one-half of the 
chest, strips of resin plaster two and a half inches wide, 



122 MINOR SURGERY. 

and sufficiently long to extend from the spine to the me- 
dian line of the sternum, are required — eighteen to twenty 
inches in length. The first strap is heated, and one ex- 
tremity is placed upon the spine opposite the lower portion 
of the chest ; it is then carried over the chest, and its 
other extremity is fixed upon the skin in the median line 
of the sternum. Straps are next applied from below up- 
ward in the same manner, each strap overlapping one- 
third of the preceding one, until the axillary fold is reached 
(Fig. 118); a second layer of straps may be applied over 
the first, if additional fixation is desired, or a few oblique 
straps may be employed. 

Adhesive straps applied in this manner very materially 
limit the motion of the chest-wall upon the affected side, 
and are frequently employed in the 
Fig. 118. treatment of fractures and disloca- 

tions of the ribs, in contusions of 
the chest, and in cases of plastic 
pleurisy when the motions of the 
chest-wall are extremely painful to 
the patient. 

Strapping of Ulcers. — To strap 
ulcers of the leg, strips of resin 
plaster one and a half inches wide, 
and sufficiently long to extend two- 
strapping over the chest, thirds of the distance around the 
limb, are required. The ulcer 
should be thoroughly cleansed, and the skin surrounding 
it well dried; the first strap, after being heated, is ap- 
plied transversely to the long axis of the leg about two 
inches below the ulcer, and is carried two-thirds of the 
distance around the limb ; another strap is applied to a 
corresponding point of the skin above this one, so that it 
overlaps one-third of the strap first applied, and it is 
carried two-thirds of the way around the limb. Addi- 
tional straps are thus applied until the ulcer is covered in, 
and the straps are carried several inches above the ulcer 
(Fig. 119). Strapping of ulcers may also be accomplished 
by using narrow straps of plaster one and a half inches in 




STRAPPING OF ULCERS. 



123 



width. The ends of two straps are placed upon the limb 
some distance below the ulcer, and the straps are brought 
up and made to cross each other so as to draw the tissues 
toward the point of crossing; a number of imbricated 

Fig. 119. 




Strapping an ulcer 01 me leg. 



straps are applied in this way until the parts are suffi- 
ciently covered in and supported (Fig. 120). Care should 
be taken to see that the straps are so applied as not to 
meet or cover the entire circumference of the limb, as by 
so doing injurious circular compression might result. 



124 



MINOR SURGERY. 



Chronic ulcers upon other portions of the body may be 
strapped in the same manner. 

Strapping of leg ulcers is usually reinforced by the 
application of a firmly applied spiral reversed or spica- 
bandage of the lower extremity. 



Fig. 120. 



; 







Strapping an ulcer of the leg. 



Strapping of ulcers of the leg applied in the manner 
described will be found a most satisfactory method 
of treating chronic ulcers in this location in patients 
who have to work during the course of treatment; the 



STRAPPING OF JOINTS. 



125 



straps need be removed only at intervals of a week, and 
if well applied, the dressing is generally a comfortable one 
to the patient. 

Strapping of Joints. — Strips of resin plaster two 
inches in width and sufficiently long to extend two-thirds 
around the joint are required. The first strap is applied 
a few inches below the joint, and straps are then applied 
over this, each strap covering in two-thirds of the preced- 
ing one until the joint is covered in and the dressing 
extends a few inches above the joint. 

Strapping will be found a satisfactory dressing in the 
treatment of sprains of joints in their acute or chronic 
state. 

Fig. 121. 




Strapping applied to ankle-joint. 



Strapping the Ankle-joint.— In applying strapping in 
sprains of the ankle- or tarsal joints* strips of rubber 



126 MINOR SURGERY. 

adhesive plaster one and a half inches in width and eigh- 
teen inches in length are required. The first strap is 
started at the junction of the middle and upper part of 
the leg, either upon the inner or the outer side, and 
applied closely to the edge of the tendo Achillis, and car- 
ried across the sole of the foot to the base of the great or 
little toe ; several of these straps are applied, covering in 
the inner or outer surface of the ankle. A strap is next 
placed with its middle at the point of the heelj the ends 
being carried to a point on the foot at the junction of the 
metatarsal bones and the tarsus ; a number of these 
ascending straps are applied, alternating with the vertical 
straps, until the ankle-joint is covered in. These straps 
should not be applied so as to meet in front of the foot or 
ankle and make circular constriction (Fig. 121). After 
the ankle has been strapped as above described, the foot 
and ankle are covered with a gauze bandage, and the 
patient is allowed to walk unon the injured foot. 

Strapping the Back. — After contusions or sprains of 
the lumbar region of the back the firm application of straps 
gives fixation and support to the parts, and relieves pain. 
The patient should be placed in such a position that the spine 
is moderately extended, and strips of plaster two and a half 
inches in width should be applied, one slightly overlapping 
the other, from the upper part of the sacrum to the lower 
ribs. The straps should be long enough to include the 
posterior half of the trunk, and several layers should be 
applied. 

POULTICES. 

This form of dressing was formerly much employed in 
the treatment of inflammatory conditions as a means of 
applying heat and moisture to the part at the same time, 
and although the use of poultices is now much restricted 
since the introduction of the antiseptic method of wound 
treatment, yet I think there are still conditions in which 
their employment is both useful and judicious. They 
are often employed with advantage in inflammatory aflPec- 



POULTICES. 127 

tions of the chest and of the abdominal organs ; and in 
inflammatory affections of the joints and of bone, com- 
bined with rest, their action is often most satisfactory. 
They constitute a form of dressing which is conducive 
to the comfort of the patient in cases of deep suppura- 
tion by their relaxing eifect upon the tissues, and their 
previous use does not prevent the surgeon from using all 
aseptic precautions in the opening and drainage of these 
abscesses, and the employment of aseptic or antiseptic 
dressings in their subsequent treatment. 

Flaxseed Poultice. — This poultice is prepared by add- 
ing first a little cold water to ground flaxseed, and then 
boiling and stirring it until the resulting mixture is of the 
consistency of thick mush. A piece of gauze or muslin i- 
next taken which is a little larger than the intended poul- 
tice, and this is laid upon the surface of a table, and with 
a spatula or knife the poultice-ma— i- spread evenly upon 
it from one-quarter to one-half an inch in thickness ; a 
margin of the muslin of one or one and a half inches is 
left, which is turned over after the poultice is spread, and 
serves to prevent it from escaping around the edges when 
applied. The surface of the poultice may be thinly spread 
over with a little olive oil, or may be covered with a layer 
of thin gauze, to prevent the mass from adhering to the 
skin. It is next applied to the surface of the skin, and i- 
covered with a piece of oiled silk, rubber-tissue, or waxed 
paper, and held in position by a bandage or a binder. 

Soap Poultice. — This is made by saturating a number 
of layers of gauze in a mixture of 1 part of green soap 
to 6 parts of water. It is then applied to the surface 
and covered with oiled muslin or waxed paper. It may be 
employed as a primary dressing for some hours to the feet 
or other parts of the body where the epidermis is thick, 
before sterilizing these parts previous to operation. 

Starch Poultice. — This poultice is prepared by mixing 
starch with cold water until a smooth, creamy fluid results ; 
boiling water is then added, and it is heated until it be- 
comes clear and attains about the same consistency as the 
starch used for laundry purposes. When sufficiently cool, 



128 MINOR SURGERY. 

it is spread upon gauze or muslin, applied to the part, and 
covered with oiled silk or waxed paper. This variety of 
poultice is principally useful in the treatment of diseases 
of the skin, especially those of the scalp accompanied by 
the formation of scabs or crusts, to facilitate their removal 
and to afford a clean surface for the application of oint- 
ments or wet dressings. 

Fermenting" Poultice. — This poultice may be prepared 
by adding yeast (two tablespoonfuls) to a mixture of flax- 
seed with hot water, making a thin poultice-mass, and 
allowing it to stand for a few hours in a warm place ; it 
rises and becomes light, and is then spread upon gauze or 
muslin and applied as required. A few ounces of porter or 
a piece of yeast-cake may be used as a substitute for the 
yeast in preparing this poultice ; animal charcoal may also 
be added to it to increase its disinfectant power. 

Antiseptic Poultice. — This is prepared by soaking a 
pad of sterilized gauze in hot bichloride or carbolic solu- 
tion and wringing it out to remove the excess of fluid. It 
is next applied to the part and covered with oiled silk or 
rubber-tissue, which may be held in place by a bandage. 
Such a dressing will absorb a considerable amount of 
discharge. 

Hot Fomentations. — Hot fomentations are employed 
to keep up the vitality of parts which have been subjected 
to injury, as seen in severe contusions resulting from rail- 
way or machinery accidents ; also to combat inflammatory 
action. Gauze (several layers in thickness) or surgical lint 
should be soaked in sterilized water having a temperature 
of 120° F. ; these are wrung out, placed over the part, and 
covered with waxed paper or rubber-tissue ; a second pad 
should be placed in the hot water, and applied as soon 
as the first-applied cloth begins to cool, and so by contin- 
uously reapplying them the part is kept constantly covered 
by a hot dressing. The use of these hot fomentations may 
in many cases require to be continued for hours before the 
desired result is obtained. Hot compresses applied in this 
manner are frequently employed in treating inflammatory 
conditions of the eye, and are also of the greatest service 



IRRIGATION. 129 

in keeping up the vitality of parts which have been sub- 
jected to severe injury interfering with their blood-supply. 
I have seen contused limbs, which were cold and seemed 
doomed to gangrene by reason of diminished blood-supply, 
have their temperature and circulation restored by the 
patient and persistent use of this dressing. After the 
vitality of such a part is restored, it should be covered 
with cotton and a flannel bandage and surrounded by hot- 
water bags or hot-water cans. 



IRRIGATION. 

This may be accomplished by allowing the irrigating 
fluid to come in contact with the wound or inflamed part 
— immediate irrigation ; or by allowing the cold or warm 
fluid to pass through rubber tubes which are in contact 
with or surround the part — mediate irrigation. 

Immediate Irrigation. — In employing immediate irri- 
gation in the treatment of wounds or inflammatory condi- 
tions, a funnel-shaped can with a stop-cock at the bottom, 
or a bucket, is suspended over the part at a distance of a 
few inches (Fig. 122), or a jar with a skein of thread or 
lamp-wick arranged to act as a siphon may be employed 
(Fig. 123). The can or jar is filled with water, and this 
is allowed to fall drop by drop upon the part to be irri- 
gated, which should be placed upon a piece of rubber 
sheeting so arranged as to allow the water to run off into 
a receptacle, to prevent wetting the patient's bed. The 
water employed may be either cold or warm, in accord- 
ance with the indications in special cases. If it is desired 
to make use of antiseptic irrigation, the water is impreg- 
nated with carbolic acid or bichloride of mercurv ; a 
1 : 5000 to 1 : 10,000 bichloride solution, or a 1 : 60* car- 
bolic acid or acetate of aluminum solution, being frequently 
employed with good results. 

Antiseptic irrigation employed in this manner will be 
found a most useful method of treating lacerated and con- 
tused wounds of the extremities in which the vitality of 
9 



130 



MINOR SURGERY. 



the tissues is much impaired; in such cases water at a 
temperature of 100° to 110° F. should be preferred to 
cool water. 

Under the use of warm irrigation it is sometimes sur- 



Fig. 122. 




Apparatus for continuous irrigation. (Esmarch.) 



prising to see tissues apparently devitalized regain their 
vitality in a short time ; the absence of tension from the 
non-introduction of sutures and firm dressings, and the 
warmth and moisture kept constantly in contact with the 
wound by this method of irrigation, are the important 
factors in the attainment of this favorable result. 
Mediate Irrigation. — In this method of irrigation cold 



COLD-WATER DRESSINGS. 



131 



or warmth is applied to the surface by means of cold or 
warm water passing through a rubber tube in contact with 



Fig. 123. 




Irrigating-apparatus. (Erichsen.) 



the part. A flexible tube of India-rubber half an inch in 
diameter, with thin walls, and sixteen or twenty feet in 
length, is applied to the limb like a spiral bandage, or is 
applied in a coil to the head, breast, or joints, and held in 
place by a few turns of a bandage ; the end of the tube is 
attached to a reservoir filled with cold or warm water 
above the level of the patient's body, and the water is 
allowed to flow constantly through the tubing and escape 
into a receptacle arranged to receive it (Fig. 124). Coils 
of rubber tubing adapted to fit different portions of the 
body, known as Leiter's coils, are frequently employed 
in this method of irrigation. 

Cold-water Dressings. — These dressings are applied 
by bringing the cold water either directly in contact with 
the part or by applying it by means of a rubber bag or 
bladder. The temperature of the water may vary from 
cool water to that of ice-water. 

These dressings are employed in local inflammatory 
conditions. A favorite method for the employment of this 



132 



MINOR SURGERY. 



dressing is by means of cold compresses, which are made 
of a few layers of gauze or surgical lint, dipped in water 
of the desired temperature and applied to the part ; they 
are renewed as soon as they become warm. When it is 
desirable to have the compresses very cold, they may be 
laid upon a block of ice or in a basin with broken ice ; 
to obtain the best results from their employment, they 
should be renewed at very short intervals. 



Fig. 124. 




Cold coil applied to arm. (Esmarch.) 

Ice-bag. — A convenient method of applying cold with- 
out moisture is by the use of the ice-bag. This is either 
a rubber bag or bladder, which is filled with broken ice 
and applied to the part. In using an ice-bag, it is better 
to cover the part first with a towel or a few layers of lint 
or gauze, which prevent the surface from becoming wet 
by absorbing the moisture which condenses upon the sur- 
face of the bag or bladder, and thus renders the dressing 
more comfortable to the patient. The ice-bag is often 
employed as an application to the head in inflammatory 



CO UNTER-IRRITA TION. 133 

conditions of the brain or membranes ; to the abdomen in 
cases of appendicitis or peritonitis, and is used also upon 
the surface of the body to control internal hemorrhage. 



COUNTER-IRRITATION. 

Counter-irritants are substances employed to excite 
external irritation, and the extent of their action varies 
according to the material used and the duration of their 
application ; superficial redness or complete destruction 
of the vitality of the parts to which they are applied may 
result. 

The use of counter-irritants under favorable circum- 
stances is found to have a decided effect in modifying 
morbid processes, and they are widely employed as local 
revulsants in cases of congestion or inflammation, and in 
cases of collapse for their stimulating effect. 

Caution should be exercised in applying counter-irri- 
tants to patients who are comatose or under the influence 
of a narcotic, for here the sensations of a patient cannot 
be used as a guide to their removal, and their too long- 
continued application when the vitality of the tissues is 
impaired may result in their superficial destruction. 

Rubefacients. — These agents, by reason of their irri- 
tating properties when applied to the skin, produce 
intense redness and congestion. 

Hot Water. — When it is desired to make a prompt 
impression upon the skin, the application of gauze, muslin, 
or flannel cloths, wrung out in hot water and renewed as 
rapidly as they become cool, will soon produce a super- 
ficial redness of the integument. 

Spirit of Turpentine. — This drug applied to the skin is 
a very active counter-irritant ; it may be rubbed upon the 
surface until redness results. When used upon patients 
whose skin is very delicate, its action may be modified by 
mixing it with an equal part of olive oil before applying 
it; this combination will be found useful as a rubefacient 
to the tender skin of young children. 



134 MINOR SURGERY. 

When redness of the skin has resulted from the appli- 
cation the skin should be wiped dry by means of a soft 
towel or absorbent cotton, to remove any turpentine from 
the surface, which by its continued contact may cause 
vesication. 

Turpentine Stupe. — This is prepared by sprinkling 
spirit of turpentine over flannel cloths which have been 
wrung out in hot water, or by dipping hot flannel in warm 
spirit of turpentine : prepared in either way, the stupe 
should be squeezed as dry as possible to remove the excess 
of turpentine before being applied to the surface of the 
body. A turpentine stupe may cause vesication if allowed 
to remain for too long a time in contact with the skin ; its 
application for from five to ten minutes will usually pro- 
duce the desired effect ; it should be removed after this 
time, and it may be reapplied if desired. 

If the patient complains of severe burning of the skin 
after the use of turpentine, the painful surface should be 
smeared freely with vaseline or lard, which will relieve 
the uncomfortable sensation. 

Tincture of Iodine. — This drug is frequently used as a 
counter-irritant in chronic inflammation. It is painted 
upon the part at intervals until irritation of the skin is 
observed, when its use is discontinued for a few days 
before reapplying the application. 

Chloroform. — A few drops of chloroform applied to the 
surface of the body by means of a piece of lint, muslin, 
or flannel, and covered by oiled silk or rubber-tissue, will 
excite a rapid rubefacient effect. 

Mustard. — Ground mustard or mustard flour, prepared 
from either Sinapis alba or Sinapis nigra, is one of the 
most commonly used substances to produce rubefacient 
action. It is generally employed in the form of the mus- 
tard plaster or sinapism, which is prepared by mixing 
equal parts of mustard flour with wheat flour or flaxseed 
meal, and adding to this sufficient warm water to make a 
thick paste ; this is spread upon a piece of old muslin, and 
the surface of the paste covered with some thin material, 
such as gauze, to prevent the paste from adhering to the 






CO UyiER-IEEITA IIOX. 1 35 

skin. Id making a mustard plaster for application to the 
skin of a child, 1 part of mustard flour should be mixed 
with 3 parts of wheat flour or flaxseed meal. 

A mustard plaster or sinapism may be allowed to 
remain in contact with the skin for a period varying from 
fifteen to thirty minutes, the time being governed by the 
sensations of the patient ; if it is allowed to remain longer, 
it may cause vesication, which is to be avoided, as ulcers 
produced by mustard are very painful and extremely slow 
in healing. ' After removing a sinapism, the irritated sur- 
face of the skin should be dressed with a piece of muslin 
or lint spread with vaseline, boric acid or oxide of zinc 
ointment. 

To excite a rapid revulsive action, the mustard foot-bath 
is often employed ; it is prepared by adding two or three 
tablespoonfuls of mustard Hour to a bucket or foot-tub 
of water at a temperature of 100° to 110 c F. ; in this the 
patient is allowed to soak his feet for a few minutes. 

Mustard Papers. — Chartoe Sinapis, which can be 
obtained in the shops ready for use, are a convenient 
means of obtaining the rubefacient action of mustard. 
They are dipped in warm water, and as they are generally 
very strong, it is well to place a layer of muslin between 
the surface of the plaster and the skin before applying it 
to the latter. 

Capsicum. — This is also -ometimes employed alone as a 
rubefacient, but it is generally nsed in combination with 
spices, forming the well-known gpiee plaster : this is pre- 
pared by taking equal parts of ground ginger, cloves, 
cinnamon, and allspice, and adding to them one-fourth 
part of Cayenne pepper ; these are thoroughly mixed, 
enclosed in a flannel bag, and evenly distributed ; a few 
stitches -hould be passed through the bag at different 
points, to prevent the powder from shifting its position ; 
before applying it. one side of the bag should be wet 
with warm whiskey or alcohol. Capsine plasters are em- 
ployed also to obtain the rubefacient effect of Cayenne 
pepper. 

Aqua Ammonia. — This may also be employed for its 



136 MINOR SURGERY. 

rubefacient action. A piece of lint saturated with the 
stronger water of ammonia, placed upon the skin and 
covered with waxed paper, and allowed to remain for one 
or two minutes, will produce a marked rubefacient effect. 

Vesicants. — Where it is desirable to make a more per- 
manent counter-irritant effect than that produced by 
rubefacients, substances are employed which by their 
action on the skin cause an effusion of serum, or of serum 
and lymph, beneath the cuticle, thus giving rise to vesi- 
cles or blisters ; they are known as vesicants. The sub- 
stance most commonly employed to produce vesication is 
Cantharis, or Spanish fly, and the preparation commonly 
used is the Ceratum cantharidw. 

Fly Blister. — This is prepared by spreading ceratum 
cantharidis upon adhesive plaster, leaving a margin one- 
half an inch in width uncovered, which will adhere to 
the skin and hold the blister in position. The time 
required for a fly blister to produce vesication is from four 
to six hours ; it should then be removed, and the surface 
covered with a flax seed -meal poultice or with a warm- 
water dressing. When the blister or vesicle is well devel- 
oped, it may be punctured at its most dependent part 
to allow the serum to escape, and it should be dressed 
with vaseline or boric ointment. If for any reason it is 
desired to keep up continued irritation after allowing the 
serum to escape, the cuticle should be cut away and the 
raw surface should be dressed with some stimulating 
material, such as the compound resin cerate. 

Cantharidal Collodion. — This may be employed to pro- 
duce vesication ; it is applied by painting several layers 
upon the skin with a brush over the part on which the 
blister is to be produced. It is a convenient preparation 
to use when the patient would disturb the ordinary blister, 
as in the case of a child or an insane patient, or where the 
surface is so irregular that the ordinary blister cannot 
well be applied. The after-treatment of blisters produced 
by cantharidal collodion is similar to that described above. 

Caution should be observed in using blisters upon the 
tender skins of children ; if employed, they should be 



CO USTEE-IBEIIA II . X 137 

allowed to remain in contact with the skin for a short 
time only. They are contraindieated in patients in whom 
the vitality of the tissues is depressed by adynamic dis- 
- and in aged persons. 

9 ngury, which is shown by frequent and painful mic- 
turition, the urine often containing blood, sometimes occurs 
from the use of cantharidal preparations as blisters. This 
condition should be treated by the use of opium and bel- 
ladonna by suppository, demulcent drinks, and warm sitz- 
baths. and by leeches to the perineum if the symptoms are 
very severe. 

avoid the development of strangury, small blisters 
should be employed, and they should not be allowed to 
remain too long in contact with the surface; cantharidal 
preparations should not be employed in cases where renal 
-ical irritation has existed or is present. Strangury 
may also be avoided by incorporating opium and camphor 
with the cantharidal cer; 

Aqua Ammonia Fortior and Chloroform. — These drugs 
may be employed to produce rapid vesication, a few dn»ps 
being placed upon the surface of the body and covered by 
an inverted watch-glass for a few minutes : or lint satu- 
rated with aqua ammonia or chloroform may be placed 
upon the skin and covered with waxed paper or oiled silk. 
Either of these agents applied in this manner, and allowed 
to remain in contact with the skin for fifteen minutes, will 
produce marked vesication. The blisters resulting 
these agents are painful, and they are only to be used 
where a rapid result is desired. 

Seguin s Method of Comiter-irritation. — This consists in 
stroking the surface of the skin lightly and rapidly with 
the point of a Paquelin cautery : the lin— : -: king may 
be made at right angles : the application is practically pain- 
less, but a verv decided counter-irritant effect is produced. 
It is employed with advantage in neuralgic affectk - 
the spine and joints, and in ses : neuritis of superficial 
nerves 

Actual Cautery. — This method of counter-irritar' 
accomplished by bringing in contact with the skin some 



138 



MINOR SURGERY. 



metallic substance brought to a high degree of tempera- 
ture. This constitutes one of the most powerful means of 
counter-irritation and revulsion ; it is rapid in its action, 
and is not more painful than some of the slower methods. 
The cauteries generally employed are made of iron, and 
are fixed in handles of wood or other non-conducting 
material, and have their extremities fashioned in a variety 
of shapes (Fig. 125). The irons are heated by placing 
their extremities in an ordinary fire, or by holding them 
in the flame of a spirit-lamp until they are heated to the 
desired point, either a white or a dull-red heat. They are 
then applied to the surface of the skin at one point, or 
drawn over it in lines either parallel to or crossing one 
another. The intense burning which follows the use of 

Fig. 125. 




Cautery irons, 

the cautery may be allayed by placing upon the cautery- 
marks compresses wrung out in ice- water or saturated with 
equal parts of lime-water and sweet oil. 

Where the ordinary cautery irons are not at hand, a 
steel knitting-needle or iron poker heated in the flame of 
a spirit-lamp or in a fire may be employed with equally 
satisfactory results. Where the cautery iron is held in 
contact with the surface for some time to make a deep 
burn, the pain of its application may be allayed by placing 
a mixture of salt and cracked ice upon the spot to be cau- 
terized, for a few minutes immediately before its applica- 



PAQUELIN'S THEBMO-CAUTERT. 



139 



tion. The cautery iron should not be placed over the 
skin covering salient parts of the skeleton or over impor- 
tant organ-. 

The actual cautery, in addition to its use in producing 
counter-irritation and revulsion, is often employed to con- 
trol hemorrhage and to destroy morbid growths. 

Paquelin's Thermo -cautery. — A very convenient and 
efficient mean- of using the thermo-eautery is the appa- 
ratus of Paquelin, which utilizes the property of heated 
platinum-sponge to become incandescent when exposed 



Fig. 126. 




Paquelin's cautery. 

to the vapor of benzole or rhigolene (Fig. 126V The 
cautery is prepared tor use by attaching the gum tube to 
the receiver containing benzole, and heating the platinum 
knife or button, which also is attached to the benzole re- 
ceiver by a rubber tube, in the flame of the alcohol lamp 
for a few moments, and then passing the vapor of benzole 



140 MINOR SURGERY. 

through the platinum-sponge, which is enclosed in the 
knife or button, by compressing the rubber bulb. The 
point may be brought to a white heat or only to a dull- 
red heat. 

This form of cautery may be employed for the same 
purposes as is that previously mentioned ; its great advan- 
tage consists in the ease with which it can be prepared for 
use. The knives heated to a dull-red heat will be found 
of great service in operating upon vascular tumors, where 
the use of an ordinary knife would be accompanied by 
profuse or even dangerous hemorrhage. Wounds made 
by the actual cautery are aseptic wounds, and when dusted 
with an antiseptic powder generally heal promptly under 
the scab without suppuration. 

BLOODLETTING. 

This procedure is often resorted to, to obtain both the 
local and the general effects following the withdrawal of 
blood from the circulation. Local depletion is accom- 
plished by means of some one of the following procedures : 
scarification, puncturation, cupping, and leeching ; and gen- 
eral depletion is effected by means of venesection or by 
arteriotomy. 

Scarification. — Scarification is performed by making 
small and not too deep incisions into an inflamed or con- 
gested part with a sharp-pointed bistoury ; the incisions 
should be in parallel lines, and should be made to corre- 
spond to the long axis of the part, and care should be 
taken in making them to avoid wounding superficial veins 
and nerves. Incisions thus made relieve tension by allow- 
ing blood and serum to escape from the engorged capil- 
laries of the infiltrated tissue of the part. Warm fomen- 
tations applied over the incisions will increase and keep 
up the flow of blood and serum. Scarification is employed 
with advantage in inflammatory conditions of the skin and 
subcutaneous cellular tissue and in acute inflammatory 
swelling or oedema of the mucous membrane, for instance, 
of the conjunctiva, and in acute inflammation of the ton- 



CUPPING. 141 

sils, tongue, and epiglottis it is an especially valuable 
procedure. 

A modification of scarification, known as deep incisions, 
is practised in urinary infiltration to establish drainage 
and to relieve the tissues of the contained urine, and to 
prevent sloughing ; in threatened gangrene and phleg- 
monous erysipelas the same procedure is adopted to relieve 
tension by permitting of the escape of blood and serum, 
and its employment is often followed by most satisfactory 
results. 

Puncturation. — This procedure consists in making 
punctures into inflamed tissues with the point of a sharp- 
pointed bistoury, which should not extend deeper than 
the subcutaneous tissue ; it is an operation similar in 
character to that just described, its object being to relieve 
tension and bring about depletion. It is employed in 
cases similar to those in which scarification is indicated, 
and is resorted to in cases of diffuse areolar inflammation 
or erysipelas. 

Cupping. — Cupping is a convenient method of employ- 
ing local depletion by inviting the blood from the deeper 
part- to the surface of the body. Cupping is accomplished 
by the use of dry or wet cups. When the former arc used, 
no blood is abstracted, and the derivative action only is 
obtained ; when wet cups are employed, there is an actual 
abstraction of blood or local depletion as well as the 
derivative action. 

Dry Cupping. — Dry cups as ordinarily applied consist of 
small cup-shaped glasses, which have a valve and stop- 
cock at their summit ; these are placed upon the skin and 
an air-pump is attached, and as the air is exhausted in the 
cup the congested integument is seen to bulge into the 
cavity of the cup. When the exhaustion is complete the 
stop-cock is turned and the air-pump is disconnected, the 
cup being allowed to remain in position for a few minutes, 
and is then removed by turning the stop-cock and allowing 
air again to enter the cup. This procedure is repeated 
until a sufficient number of cups have been applied (Fig. 
127). 



142 



MINOR SURGERY. 



In cases of emergency, when the ordinary cupping- 
glasses and air-pump are not available, a very satisfactory 
substitute may be obtained by taking a wineglass and 
burning in it a little roll of paper, or a small piece of 
lint or paper wet with alcohol, and before the flame is 
extinguished rapidly inverting it 
upon the skin ; or the air may be 
exhausted by the introduction, for a 
moment or two, of the flame of a 
spirit-lamp into the cup. Applied 
in this manner, cups will draw as 
well as when the more complicated 

Fig. 128. 




Cupping-glass and air-pump. 



Scarificator. 



apparatus is used ; and when they are to be removed, it is 
only necessary to press the finger on the skin close to the 
edge of the cup until air enters it, when it will fall off. 
Although dry cups do not remove blood directly, there 
is often an escape of blood from the capillaries into the 
skin and cellular tissue, as is evidenced by the ecchymosis 
which frequently remains for some days at the seat of the 
cup-marks. 

Wet Cupping. — When the abstraction of blood as well 
as the derivative action is desired, wet cups are resorted 
to, and here it is necessary to have a scarificator as well as 
the cups and air-pump (Fig. 128). 

Before applying wet cups, the skin should be washed 
carefully with bichloride or carbolic solution, and the 



LEECHING. 143 

scarificator should also be sterilized by boiling. A cup 
is first applied to produce superficial congestion of the 
skin : this is removed, and the scarificator is applied and 
the skin is cut by springing the blades. The cups are 
immediately reapplied and exhausted, and they are kept 
in place as long as blood continues to flow. When the 
vacuum is exhausted and blood ceases to flow, they should 
be removed and emptied, and may be reapplied if it is 
desirable to remove more blood. A sharp-pointed bistoury 
which has been sterilized may be employed to make a few 
incisions into the skin instead of the scarificator, and im- 
provised cups may be employed if the ordinary cupping- 
apparatus cannot be obtained. 

After the removal of wet cups the skin should be 
washed carefully with a bichloride or carbolic solution, 
and an antiseptic dressing should be placed over the 
wounds and held in place by a roller-bandage. 

Leeching. — The abstraction of blood by leeching is 
not much employed at the present time. Two varieties of 
leeches are used — the American leech, which draws abont 
a teaspoonful of blood, and the Swedish leech, which draws 
three or four teaspoonfuls. 

Before applying leeches the skin should be carefully 
washed, and the leech should be placed upon the part 
from which the blood is to be drawn, and confined to 
this place by inverting a tumbler or glass jar over it ; if it 
does not bite or take hold, a little milk or blood should be 
smeared upon the surface, which will generally secure the 
desired result. As soon as the leech lias ceased to draw 
blood it is apt to let go its hold and fall off: if. however, 
it is desired to remove leeches, they may be made to let go 
their hold by sprinkling them with a little salt. After the 
removal of leeches bleeding from the bites may be encour- 
aged, if desirable, by the application of warm fomenta- 
tions. Leech-bites should be washed with a bichloride or 
carbolic solution, and a compress of bichloride or iodoform 
gauze placed over them and secured by a bandage. 

It sometimes happens that free bleeding continues from 
the leech-bite after the removal of the leeches ; in this 



144 



MINOR SURGERY. 



Fig. 129. 



event, if a compress does not control the hemorrhage, the 
bleeding point should be touched with the point of a steel 
knitting-needle heated to a dull-red heat, and if this fails 
to control the bleeding a delicate harelip pin should be 
passed through the skin under the bite and a twisted suture 
thrown around this ; the wound should then be washed 
and dressed as previously described. 

In applying leeches in or near the mucous cavities care 
should be taken to see that they do not escape into the 
cavities and pass out of reach. Leeches should not be 
employed directly over inflamed tissue, but should be ap- 
plied to parts surrounding it ; they should 
not be allowed to take hold directly over a 
superficial artery, vein, or nerve, and should 
never be applied to a part where there are 
delicate skm and a large amount of loose 
cellular tissue, as in the eyelid or scrotum, 
as unsightly ecchymoses will result, which 
persist for some time. Leeches should not 
be used a second time. 

The Mechanical Leech. — The mechanical 
leech is an apparatus which has been con- 
structed to take the place of the leech ; it 
consists of a scarificator, cup, and exhaust- 
ing syringe or air-pump (Fig. 129). In 
using this apparatus, after the scarificator 
has been used the piston of the exhausting- 
instrument should be drawn out slowly, 
which secures a better flow of blood than if 
a sudden vacuum is created. 

Venesection. — Venesection, as its name 
implies, consists in the division of a vein, 
and it is the ordinary operation by which 
general depletion or bleeding is accomplished. Vene- 
section at the bend of the elbow is the operation which 
is now usually resorted to for general bloodletting ; the 
vein selected is the median cephalic, which is further 
from the line of the brachial artery than the median 
basilic vein (Fig. 130). 



Mechanical 
leech. 



VENESECTION. 



145 



To perform venesection, the surgeon requires a bistoury 
or lancet — the spring lancet was formerly much used, but 
it is not employed at the present time — several bandages, 
a small antiseptic dressing, and a basin to receive the blood. 

The patient's arm should carefully be cleansed, washed 
over with a bichloride solution, and a few turns of a 
roller-bandage placed around the middle of the arm, 
being applied tightly enough to obstruct the venous circu- 
lation and make the veins below become prominent, but 
not tight enough to obstruct the arterial circulation. The 

Fig. 130. 




Venesection. (Heath.) 



patient at the same time should be instructed to grasp a 
stick or a roller-bandage and work his lingers upon it. 
The surgeon should next assure himself that there is no 
abnormal artery beneath the skin, and having selected 
the vein, the median cephalic by preference, he steadies 
it with the thumb and passes the point of the bistoury or 
lancet beneath it and cuts quickly outward, making a free 
skin opening. The blood usually escapes freely, and the 
amount withdrawn is regulated by the condition of the 
pulse and the appearance of the patient. For this reason 
it is better to have the patient sitting up or semi-reclining 
when venesection is performed, as the surgeon can appre- 
ciate better the constitutional effects of the loss of blood 
while the patient is in this position. 

When a sufficient quantity of blood has been removed, 
the thumb is placed over the wound of the vein and the 



LO 



146 MINOR SURGERY. 

bandage removed from the arm above. The wound is next 
washed with a bichloride solution, and a compress of anti- 
septic gauze is applied over the wound and held in posi- 
tion by a bandage, which should be so applied as to envelop 
the limb from the fingers to the axilla. The dressing need 
not be disturbed for five or six days, at which time the 
wound is usually found to be healed. 

Wounds of the brachial artery have occurred in opening 
the veins at the bend of the elbow, but if care is taken, 
this accident should not take place. 

Venesection may be practised on the external jugular 
vein when, from excess of fat or in the case of children, 
the veins at the bend of the elbow cannot be easily found. 
The vein is rendered prominent by placing the thumb or 
a pad over the vein at the outer edge of the sternocleido- 
mastoid muscle just above the clavicle. The vein is next 
opened over this muscle by an incision parallel to its fibres. 
After a sufficient quantity of blood has escaped, the wound 
is washed with an antiseptic solution and closed by a com- 
press of antiseptic gauze held in position by a bandage 
carried around the neck. 

The internal saphenous vein is also sometimes selected for 
venesection, and here care should be taken not to wound 
the accompanying nerve which lies directly behind the vein. 

Arteriotomy. — This operation is now scarcely ever per- 
formed; but if done, the vessel generally selected is the 
anterior branch of the temporal artery. The position of 
the vessel is fixed by the finger and thumb, and it is 
opened by a transverse incision with a bistoury. After a 
sufficient quantity of blood has escaped, the wound is in- 
spected, and if the vessel is not completely divided, its 
division is completed and the ends of the vessel should be 
secured with ligatures, and the wound irrigated with an 
antiseptic solution and closed with sutures. A gauze 
compress should next be applied and held in position by 
a firmly applied bandage. 

Transfusion of Blood. — This operation may be em- 
ployed to introduce a certain quantity of blood into the 
circulation of a patient who has suffered from profuse 



INJECTION OF SALINE SOLUTION. 147 

hemorrhage ; it is rarely employed at the present time, 
being almost entirely superseded by the intravenous injec- 
tion or infusion of normal saline solution. There are two 
methods by which transfusion may be effected : the direct, 
by which the blood is conveyed directly and without ex- 
posure to the air from the bloodvessel of one person to that 
of another ; and the indirect, in which the blood is first 
drawn from one person and is then injected into the 
veins of another, being deprived of its fibrin before being 
injected. 

Arterial Transfusion. — This procedure, which con- 
sists in injecting defibrinated venous blood into an artery, 
has been occasionally practised. An artery, usually the 
radial at the wris^ or the posterior tibial behind the inner 
malleolus, is exposed and secured by a ligature ; it is then 
opened on the distal side of the ligature, and the point of 
a canula or the nozzle of a syringe is introduced, directed 
toward the distal extremity of the limb, and blood, which 
has previously been defibrinated, is slowly injected. If 
this procedure is practised, normal saline solution should 
be substituted for defibrinated blood. When a sufficient 
quantity has been introduced, the canula is removed, the 
division of the artery is completed and its extremities se- 
cured by ligatures, and the wound is closed and dressed. 

Auto -transfusion. — This procedure is recommended in 
cases of excessive hemorrhage to support a moribund 
patient until other means of resuscitation can be adopted. 
It consists in the application of rubber or muslin band- 
ages to the extremities for the purpose of forcing the 
blood toward the vascular and nervous centres. 



INTRAVENOUS INJECTION OF SALINE SOLUTION. 

It has been proved by experiments and by clinical 
experience that human blood is not more efficacious in 
supplying volume to and restoring a rapidly failing circu- 
lation than normal salt solution, and as the latter can be 
obtained with much more ease than blood, its use has 



148 MINOR SURGERY. 

largely superseded the former. The solution should be 
at a temperature of 110° or 120° F. 

A vein of the patient, at the elbow, should be exposed, 
and should have placed under it, about one-half inch 
apart, two catgut ligatures ; the distal ligature is then tied 
and an opening is made into the vein between the liga- 
tures ; a canula is next inserted into the opening in the 
vein, and is secured in position by tying the proximal 
ligature. The canula is first filled with the saline solu- 
tion, and is then connected with a funnel by means of a 
rubber tube (Fig. 131), which is filled with saline solution 
to displace the air, and upon raising the funnel above the 
part the solution enters the vein ; care should be taken to 
see that the funnel is kept well supplied with the solution 
until a sufficient quantity has been introduced. The 
quantity introduced is regulated by the condition of the 
patient's pulse. 

Saline solution may also be introduced into a vein by 

Fig. 131. 




Funnel and tube for intravenous injection. 

means of a syringe when the apparatus described cannot 
be obtained. 

Infusion of Saline Solution — Hypodermoclysis. — 
The introduction of saline solution into the cellular tissue 
has been followed by results equally as satisfactory as those 



ARTIFICIAL RESPIRATION. 149 

obtained by intravenous injection, and this procedure is 
now very frequently employed. 

The saline solution is conveyed into the cellular tissue 
through a large hypodermic needle, which should be ster- 
ilized by boiling, and is then introduced into the connec- 
tive tissue, being previously connected by a rubber tube 
with a reservoir containing warm sterilized salt solution. 
The usual situations for the introduction of the solution 
are the external portions of the thighs and the anterior 
and lateral portions of the abdominal walls. As much as 
two or three pints of the solution are often introduced in 
this manner, with good results. Infusion of saline solution 
may be used with most satisfactory results in cases who 
have suffered from profuse hemorrhage, and has also proved 
of great service in cases of shock, and has a distinct value 
in the treatment of septicaemia and uraemia. 



ARTIFICIAL RESPIRATION. 

This procedure is resorted to in cases of threatened 
deatli from apnoea consequent upon drowning, profound 
anesthetization, electric shock, or the inhalation of irre- 
spirable gases, or when from any cause there is interfer- 
ence with the function of breathing. Before resorting to 
artificial respiration, care should be taken to see that 
nothing is present in the mouth or air-passages which will 
obstruct the entrance of air into the lungs, such as mucus, 
foreign bodies, or liquids, and also that all tight clothing 
interfering with the free expansion of the chest-walls is 
removed from the chest. 

In cases where the apnoea is due to the presence of a 
foreign body in the larynx or trachea, it is evident that no 
efforts at respiration can be successful until the air-pas- 
sages are freed from the occluding body ; and if it cannot 
be removed through the mouth, tracheotomy should be 
performed before artificial respiration is attempted ; the 
tracheal wound should be held open by retractors, which 
in a case of emergency can be made from bent hairpins, 



150 MINOR SURGERY. 

or by a dressing-forceps or a tracheotomy- tube, if one be 
at band. 

When artificial respiration is resorted to, the operator 
should persevere with it for some time, even when no 
apparent spontaneous respiratory movements are excited ; 
for resuscitation has been accomplished in seemingly hope- 
less cases by patient perseverance with the manipulations. 
When the first natural respiratory movement is detected, 
the operator should not cease making artificial respiration, 
but should continue these movements in such a way as to 
coincide with the spontaneous inspiratory and expiratory 
movements until the breathing has assumed its regular 
character. 

The temperature of the body should also be restored by 
friction to the surface by the hands or by rough towels 
and hot-water bottles, and warm coverings should be 
applied for the same object. 

Mouth-to-mouth Inflation. — This method of artificial 
respiration has been resorted to in cases of great emer- 
gency, especially in very young children. The operator 
draws the tongue forward, closes the nostrils, and applies 
his mouth directly to the mouth of the patient, and by a 
deep expiratory effort endeavors to force air into the chest; 
when this is accomplished, the air can be expelled from the 
lungs by pressure upon the walls of the chest, and the 
procedure should be repeated about sixteen times in a 
minute. The same object may be accomplished by pass- 
ing a flexible catheter into the trachea through the mouth, 
and the lungs can be inflated by the operator blowing into 
the catheter. 

Direct Method of Artificial Respiration (Howard's). 
— This method of artificial respiration is at the present 
time considered the most efficacious, and is the one adopted 
by the United States Life-saving Service ; and although 
the rules given are for the resuscitation of cases of ap- 
parent drowning, the same procedures may be adopted in 
cases of apncea arising from other causes. 

The rules laid down by Dr. Howard are as follows : 

Rule I. — " To expel water from the stomach and lungs, 






ARTIFICIAL RESPIRATION. 



151 



strip the patient to the waist, and if the jaws are clenched 
separate them and keep them apart by placing between the 
teeth a cork or a small piece of wood. Place the patient 
face downward, the pit of the stomach being raised above 
the level of the mouth by a roll of clothing placed beneath 
it (Fig. 132). Throw your weight forcibly two or three 
times upon the patient's back over the roll of clothing, 
so as to press all fluids in the stomach out of the mouth." 



Fig. 132. 




First manipulation in Howard's method. 

The first rule applies only to cases of drowning, and in 
using Howard's method in apncea from other causes it is 
to be omitted. 

Rule II. — " To perform artificial respiration, quickly 
turn the patient upon his back, placing the roll of clothing 
beneath it so as to make the breast-bone the highest point 
of the body. Kneel beside or astride of the patient's hips. 
Grasp the front part of the chest on either side of the pit 
of the stomach, resting the fingers along the spaces be- 
tween the short ribs. Brace your elbows against your 
sides, and steadily grasping and pressing forward and up- 
ward throw your whole weight upon the chest, gradually 
increasing the pressure while you count one — tico — three. 
Then suddenly let go with a final push which springs you 



152 MINOR SURGERY. 

back to your first position (Fig. 133). Rest erect upon 
your knees while you count one — two ; then make press- 
ure as before, repeating the entire motions at first about 
four or five times a minute, gradually increasing them 
to about ten or twelve times. Use the same regularity 
as in blowing bellows and as seen in the natural breath- 
ing which you are imitating. If another person is pres- 
ent, let him with one hand, by means of a dry piece of 
linen, hold the tip of the tongue out of one corner of the 
mouth, and with the other hand grasp both wrists and pin 
them to the ground above the patient's head." This 
method may be employed in cases of stillbirth, or in 
young children, the operator holding the body of the 

Fig. 133. 




Direct method of artificial respiration. 

child in his left hand and compressing it with the right 
hand. 
Silvester's Method of Artificial Respiration. — In 

employing this method of artificial respiration the patient 
should be placed on his back upon a firm flat surface ; a 
cushion of clothing is placed under the shoulders, and the 
head should be dropped lower than the body by tilting 
the surface on which he is laid. The mouth being cleared 



AR TIFICIA L RESPIRA TION. 



153 



Fig. 134. 




Silvester's method— inspiration. (Esmarch.) 



Fig. 135. 




Silvester's method —expiration. (Esmarch.) 



154 MINOR SURGERY. 

of mucus or foreign substances, the tongue is drawn for- 
ward and secured to the chin by a piece of tape tied 
around it and the lower jaw, or may be pulled out of the 
mouth and held by an assistant. The operator, standing 
at the patient's head, grasps the arms at the elbows and 
carries them first outward and then upward until the 
hands are brought together above the head ; this repre- 
sents inspiration (Fig. 134) ; they should- be kept in this 
position for two seconds, after which time they are brought 
slowly back to the sides of the thorax and pressed against 
it for two seconds; this represents expiration (Fig. 135). 
These movements are repeated fifteen times in a minute 
until the breathing is restored or it is evident that the 
case is a hopeless one. 

Laborde's Method of Artificial Respiration. — 
Laborde has shown that systematic and rhythmic traction 
upon the tongue is a powerful means of restoring the 
respiratory reflex, and consequently the function of respi- 
ration. The procedure is accomplished as follows : The 
body of the tongue is seized between the thumb and 
fingers, and traction is made upon it with alternate relaxa- 
tion, fifteen or twenty times a minute, imitating the func- 
tion of respiration, taking care to draw well on the tongue. 
When a certain amount of resistance is felt, it is a sign 
that the respiratory function is being restored. Noisy 
respiration first occurs, termed by Laborde hoquet inspira- 
teur (inspiratory hiccough). Tongue forceps or dressing 
or haemostatic forceps may be used in place of the fingers 
to grasp the tongue. It is important to persist in the 
manipulations for half an hour to an hour, unless the case 
is absolutely hopeless. This procedure, which cannot be 
employed with advantage when there is fixation of the 
tongue from inflammation or malignant disease, has been 
employed with success in cases of drowning, toxic asphyxia, 
asphyxia during anaesthesia, and arrest of respiration from 
electric shock. 

Forced Respiration. — By this method of artificial 
respiration air is forcibly passed into the lungs. This 
procedure is strongly advocated by Fell, who has devised 



FORCED RESPIRATION. 155 

an apparatus by which it may be satisfactorily accom- 
plished. Professor H. C. Wood has also made use of 
forced respiration in the resuscitation of animals with an 
apparatus somewhat similar to that devised by Fell, with 
good results. Wood's apparatus consists of a pair of bel- 
lows, a few feet of rubber tubing and a face-mask of rubber, 
and one or two intubation-tubes; the mask or intubation- 
tube is attached to one end of the rubber tube and the 
bellows to the other extremity. The mask is applied 
over the mouth, or, if this is not used, the intubation-tube 
is introduced into the larynx, and air is forced into the 
lungs by working the bellows. He also advises that in 
the tubing a double metal tube be introduced, with the 
openings so placed that their size can be so regulated by 
turning the outer tube that the operator can allow any 
excess of air thrown by the bellows to escape. 

The apparatus of Fell, which he has used in a number 
of cases with good results, consists of a mouth-mask or 
tracheotomy-tube, and a tube connected with the air-con- 
trol valve, which is attached to an air-warming apparatus, 
which in turn is connected with a bellows by another 
tube. By means of this apparatus air is forced into the 
lungs, and allowed to escape, when the lungs have been 
expanded, by the elasticity of the lung tissue and the chest 
walls. 

Forced respiration has proved of value in cases of nar- 
cotic poisoning and other accidents, in which death is pro- 
duced by paralysis of the respiratory centres. 

Aspiration. — This procedure is adopted to remove fluid 
from a closed cavity without the admission of air, and the 
instrument which is employed to accomplish this object is 
known as an aspirator. The form of aspirator most 
generally employed is that of Potain. 

Potain's Aspirator. — This consists of a glass bottle, into 
the stopper of which is introduced a metallic tube, which is 
connected with two rubber tubes, one of which is connected 
with an exhausting-pump, and the other with a delicate 
canula carrying a fine trocar ; the apparatus is provided 
with stop-cocks to prevent the admission of air (Fig. 



156 



MINOR SURGERY. 



136). In using this aspirator, the air is exhausted from 
the bottle by using the air-pump ; the canula enclosing the 
trocar is next pushed through the tissues into the cavity 
containing the fluid to be removed : the trocar is then 
removed, and upon opening the stop-cock the fluid is 
forced out of the cavity by atmospheric pressure and 
passes into thp bottle or receiver. If the fluid contains 
masses of lymph or clots which block the canula, inter- 

Fig. 136. 







Potain's aspirator. 

rupting the flow of fluid, a stylet may be passed through 
the canula to free it from the obstruction. 

To diminish the pain produced in introducing the trocar 
and canula, the skin at the point to be punctured may be 
rendered less sensitive by holding in contact with it for a 
few minutes a piece of ice wrapped in a towel, or a towel 
containing broken ice and salt. Care should also be taken 
to see that the trocar and canula have been perfectly steril- 
ized ; to accomplish this, they should be carefully washed 
and placed in boiling water or a 5 per cent, carbolic solu- 
tion before being used. In introducing the trocar and 



TEE STOMACH-TUBE. 157 

canula, the operator should be careful to avoid injuring 
important veins, arteries, or nerves. 

After removing the canula the small puncture should 
be dressed with a compress of antiseptic or iodoform gauze, 
held in place by a bandage or adhesive straps. 

The aspirator is frequently employed in cases of hydro- 
thorax, empyema, and ascites, to evacuate the contents of 
cold abscesses in diseases of the hip and spine, and to 
remove the contents of a distended bladder until a more 
radical operation can be performed. It is also a valuable 
instrument for diagnostic purposes, being frequently used 
to ascertain the character of the contents of deep-seated 
tumors containing fluid. 

The Stomach : tube. — This consists of a partially flexi- 
ble tube about twenty-eight inches in length and three- 
eighths of an inch in diameter, which is introduced while 
the patient is in the sitting posture, the head being thrown 
backward so as to bring the mouth and gullet as nearly 
as possible in the same line (Fig. 137). The tube being 

Fig. 137. 



The stomach-tube. 

warmed and oiled, the surgeon standing in front of the 
patient passes it directly back to the pharynx, at the same 
time introducing the index-finger of the left hand to guide 
its point over the epiglottis ; it is then passed gently 
downward into the stomach. If any obstruction is met 
with in its passage, it should be withdrawn a little and 
then pushed gently downward ; all manipulations should 
be made without much force, to avoid perforating the wall 
of the oesophagus. 

The introduction of the stomach-tube may be required 
for the evacuation of poisons from the stomach or to wash 
out the cavity of this viscus. It may also be used to intro-, 
duce liquid nourishment into the stomach of patients who 
are unable or unwilling to swallow food. In introducino- 



158 MINOR SURGERY. 

liquid nourishment a syringe or funnel is fitted to the free 
end of the tube, which has been passed into the stomach ; 
the syringe or funnel having been filled with milk or beef- 
tea or broth, the contents are injected gently or allowed to 
run into the stomach. 

In cases of poisoning, where it is desirable to withdraw 
the contents of the stomach and to wash out the organ, a 
stomach-tube and syringe may be employed ; several 
syringefuls of warm water are first thrown into the 
stomach and then withdrawn by suction, but in such 
cases the use of the stomach-pump will be found more 
satisfactory. 

Lavage. — In the recently introduced method of treating 
disorders of the stomach by irrigation, the introduction of 
a flexible rubber stomach-tube is required ; the tube here 
employed is from twenty-four to thirty inches in length, 
and the fluid is introduced by means of a funnel attached 
to its free extremity, or it may be attached to a stomach- 
pump. 

The Stomach-pump. — This consists of a brass syringe, 
the nozzle of which is connected with two tubes, one at the 
end, the other at the side. The passage of fluid through the 
nozzle is regulated by a valve controlled by a lever. The 
nozzle of the pump is attached to a stomach-tube, and the 
end of the lateral tube is placed in a pan of warm water. 
By withdrawing the piston and opening the valve, water 
may be drawn from the basin, and by closing the valve 
and depressing the piston it is forced through the stomach- 
tube into the stomach ; when a sufficient quantity has been 
injected in this manner, by reversing the action of the 
valve the fluid is drawn out of the stomach and dis- 
charged through the lateral tube into a basin. This 
manipulation is continued until the water returns clear 
and the stomach has been completely washed out. The 
stomach-pump shown in Fig. 138 may also be employed. 

(Esophageal Bougie. — This instrument — which may be 
passed through the oesophagus into the stomach for the 
purpose of diagnosis or for the purpose of dilating strict- 
ures of the oesophagus — is employed in exactly the same 



THE RECTAL TUBE. 



159 



manner as the stomach-tube, and, as in the case of the 
latter instrument, it should be introduced without the use 
of much force, as perforations of the oesophagus have fol- 
lowed the forcible introduction of such instruments. 

The Rectal Tube. — The introduction of the rectal tube 
is best accomplished by placing the patient upon his left 
side, and the surgeon should introduce his index finger 
well oiled into the rectum and guide the tube upon this 
through the anus, when by gentle pressure it is gradually 
passed into the rectum ; if a stricture exists in the rectum 



Fig. 13S. 




Stomach-pump. 

within reach of the finger, the latter should be used to 
guide the tube through the opening in this ; if the tube 
becomes caught in a transverse fold of the mucous mem- 
brane and doubles upon itself, it should be withdrawn 
and a fresh attempt made to pass it. In passing a rectal 
tube all manipulation- should be made with extreme 
gentlene— . as it has been shown that its passage is not 
without danger, perforations of the intestine having fol- 
lowed its use in some cases. In ease:? of stricture of the 
rectum high up, the operator has to depend upon the 
sense of resistance experienced in passing the tube, and 



160 MINOR SURGERY. 

in such cases the manipulations should be most carefully 
made. When the rectal tube is employed to introduce 
fluid into the large intestine, the fluid may be introduced 
by means of a syringe, or by pouring it into a funnel 
attached to the free end of the tube, or by attaching the 
tube to a fountain syringe, thus allowing the liquid to pass 
slowly into the intestine. 

The rectal tube is often employed with good results 
in irrigating the large intestine, relieving the intes- 
tine of flatus, and in introducing water or oil into the 
intestine in cases of intestinal obstruction, and in those 
cases where the obstruction results from intussuscep- 
tion or fecal accumulations its use will often prove satis- 
factory. 

Rectal Bougies. — These instruments are made of India- 
rubber or the same material as the English flexible cathe- 
ter, and are of various sizes. They should first be oiled, 
and are introduced in the same manner as the rectal tube. 
They are generally employed in cases of stricture of the 
rectum, and should be introduced with great care to 
avoid perforating the wall of the rectum ; this accident 
has occurred in the hands of skilful surgeons. A very 
satisfactory substitute for a rectal bougie is a tallow candle, 
one end of which is melted or rubbed down to a conical 
shape. 

Enemata. — These may be administered by means of an 
ordinary syringe, or by means of a gravity or fountain 
syringe ; the precautions which should be observed are to 
introduce the nozzle of the syringe gently and in the right 
direction, as perforation of the lower portion of the rectum 
has taken place from careless and forcible introduction 
of the nozzle of the enema-syringe ; the fluid should also 
be injected slowly, as by so doing there is less resistance 
and less tendency for the patient to pass the fluid before 
the desired quantity has been introduced. 

The enema most commonly employed to empty the lower 
bowel is made by adding a tablespoonful of sweet oil and 
two teaspoonfuls of spirit of turpentine to one or two 
pints of warm water in which a little Castile soap has been 



VACCINATION. 161 

dissolved ; warm water and sweet oil are also frequently 
used for the same purpose. 

Glycerin Enema. — One or two teaspoonfuls of glycerin 
injected into the rectum, or a suppository made of glycerin, 
will often be found an efficient substitute for the larger 
enemata of water. 

Nutritious Enema. — When it is found necessary to resort 
to feeding by the rectum, the substances employed should 
be injected into the rectum by means of a syringe, and 
care should be taken that the quantity is not too large, and 
that it is of such a nature as not to cause irritation of the 
walls of the rectum, or it will not be retained ; two to four 
ounces in the case of an adult is generally a sufficient 
quantity to inject at one time. 

Peptonized milk or beef-juice, or the yolk of an egg 
beaten up with milk, is often employed, and any unirri- 
tating drugs may be mixed with the enema and adminis- 
tered at the same time. 

Vaccination. — This is a minor surgical procedure which 
every physician is called upon to perform. The surface 
may be prepared for the reception of the lymph by abrad- 
ing the skin at one or two points with a dull lancet, or 
by making several superficial incisions with a knife, or 
by scratching the surface of the skin with the ivory point 
charged with lymph, in lines with crossing lines, cross- 
scratch, until a little serum exudes. It is not advisable 
to draw blood, which washes away the. lymph, and for 
this reason we prefer the abraded surface made by the dull 
knife or the ivory point. 

The lymph used may be the humanized or the bovine. 

Bovine lymph or virus, which is now most generally em- 
ployed, is taken from the vaccine vesicles upon the udders 
and teats of heifers. The lymph may be mixed with ster- 
ilized glycerin and placed in line glass tubes, which are 
sealed ; or ivory points or quills are dipped in the lymph 
and allowed to dry, and in using these they are dipped in 
water for a moment, to moisten the lymph, before being 
applied to the abraded surface. The ivory-point is 
one of the most convenient means of vaccination, as 
11 



162 MINOR SURGERY. 

the surface may be abraded with it before the lymph is 
applied. 

It has recently been advised that antiseptic precautions 
be exercised in performing vaccination, and although all 
of the details cannot be carried out, we have found that 
the exercise of care as regards cleanliness of the surface 
has been followed by much fewer inflammatory complica- 
tions in vaccination wounds. 

The surface to be abraded, usually the left arm below 
the deltoid, is first washed with soap and water, then with 
a 1 : 2000 bichloride solution, or with alcohol, and finally 
washed with sterilized water. Two points of this surface, 
an inch apart, are then abraded by using a knife which 
has been washed or dipped in boiling water, or by using 
the ivory-point which has been dipped in water that has 
been boiled and cooled. When the surface has been pre- 
pared in the manner described, the moistened virus is 
rubbed upon it and allowed to dry. Vaccination upon 
the leg, which is practised by some physicians to prevent 
the scar from showing, I think is not to be recommended, 
and I never practise it in this situation, as it is more diffi- 
cult to keep this part at rest. 

Hypodermic Injections. — The syringe used to make 
hypodermic injections is provided with a perforated 
needle, which is passed into the cellular tissue (Fig. 139). 
Care should be taken to see that the instrument and needle 
are perfectly clean before being used ; they should be 
rendered aseptic by soaking them for a few minutes in 
boiling water or in a 5 per cent, carbolic solution. Hypo- 
dermic injections are generally made into parts in which 
the cellular tissue is abundant, and great care should be 
observed to avoid introducing the needle into a large vein 
or artery, as by neglect of this precaution serious symp- 
toms have resulted, from the drug being thrown rapidly 
into the circulation instead of being slowly absorbed from 
the subcutaneous cellular tissue ; injury of superficial 
nerves should also be avoided. Care should also be taken 
to see that the solutions employed are sterilized if possi- 
ble, and freshly made solutions should be preferred. 



INJECTION OF ANTITOXINS. 



163 



To avoid using solutions for hypodermic use which 
undergo change in keeping, it will be found convenient 
to use the compressed pellets which are prepared by manu- 
facturing chemists, the alkaloids being compressed with a 
little sulphate of sodium, which increases their solubility, 



Fig. 139. 



=eSP 




Hypodermic syringe and needles. 

the solution being prepared with boiled water just before 
being used. 

The portions of the body usually selected for hypo- 
dermic injection are the outer surface of the thighs or 
arms and the anterior surface of the forearms. In making 
a hypodermic injection, the syringe is charged and the 
needle is fastened to the nozzle of the syringe ; the skin 
is next pinched up and the needle is quickly thrust 
through this into the cellular tissue (Fig. 140) ; the syringe 
is then emptied by pressing down the piston, and when 
the cylinder is empty the needle is withdrawn. 

Fig. 140. 




Method of giving a hypodermic injection. 

Injection of Antitoxins. — In the treatment of diseases 
such as diphtheria, anthrax, septicaemia, pneumonia, and 
tetanus by the injection of serum, the hypodermic method 



164 MINOR SURGERY. 

is made use of; in using antitoxin injections in diphtheria 
the dose of the antitoxin is proportionate to the age and 
weight of the patient as well as to the severity and dura- 
tion of the disease. A child three years old should be 
given 2000 units ; an adult, not less than 3000 units ; and 
the injection should be repeated in twelve to twenty-four 
hours. Before employing the injection the skin should be 
sterilized, and the best variety of syringe to employ is one 
holding about 20 c.c. (Fig. 141). 

It is well to have the needle connected with the syringe 
by a short rubber tube, so that the needle will not be 
broken if the patient struggles. The injections are 
usually made below the angle of the scapula or in the 

Fig. 141. 



H. K. MULFORD CO., PHILADA. jjnj 

Syringe for serum-injection. 



lumbar region, and the serum is introduced slowly to 
avoid local reaction. 

Coley's Fluid. — This fluid, which consists of the mixed 
toxins of streptococcus erysipelatis and bacillus prodigiosus, 
has been employed in the treatment of sarcoma with some 
success. It has been especially used in inoperable sarcomata 
of the abdomen and recurrent and secondary sarcomata 
of bone. Five to ten minims are injected hypodermically 
at intervals of a few days, depending upon the amount of 
constitutional reaction produced, and the dose is gradually 
increased if the patient bears it well. The treatment should 
be continued for some weeks until it is shown that no re- 
sults are obtained or the growths are diminishing. 

Injections of Mercury in Syphilis.— '-Injections of mer- 
cury may be made into the subcutaneous tissue of the 
loins, buttocks, or scapular regions in the treatment of 



EXPL ORISG-NEEDLE. 165 

syphilis. Injections may also be into the veins. The 
solution most commonly used is a 1 per cent, solution of 
the cyanide of mercury, 20 minims being injected every 
day or on alternate days. 

Exploring-needle. — This consists of a fine-grooved 
needle fitted into a handle (Fig. 142), which is introduced 
into tumors or swellings to ascertain the nature of their 
contents, and its use is often of service for purposes of 

Fig. 142. 



Exploring-needle. 

diagnosis. The exploring-trocar (Fig. 143) is employed 
for the same purpose, or the needle of the hypodermic 
syringe or a fine needle attached to an aspirator may be 
used for a like purpose. When either the exploring-needle 
or trocar is employed, care should be taken to see that it 
is rendered perfectly aseptic before being used ; otherwise 
its employment is not without danger, for we have seen 
the introduction of an exploring-needle into an effusion 
in a joint for diagnostic purposes followed by infection 

Fig. 143. 



Exploring-trocar. 

and destruction of the joint, which subsequently necessi- 
tated its excision. 

Skin-grafting. — This is a surgical procedure which 
may be employed to fill a gap in the tissues or to hasten 
cicatrization where large granulating surfaces are exposed, 
such as result from extensive operations and from burns. 

The operation consists in applying shavings of the epi- 
dermis, or of the epidermis and cutis together, to the 



166 MINOR SURGERY. 

granulating surface and holding them in contact with it 
ibr a few days ; the grafts often seem to disappear, but at 
the end of a few days, if the part is closely inspected, 
bluish-white points will be seen to occupy the positions at 
which the grafts were applied, which become converted 
into isolated cicatrices from which the healing process 
rapidly extends. To have a successful result follow the 
use of skin-grafts, the surface of the ulcer should be 
healthy, and its surface as Avell as the surrounding skin 
rendered aseptic, and the grafts should be applied at a 
number of points. 

The surface from which the grafts are to be taken 
should also be rendered aseptic, and the skin should be 
removed by scissors or by a sharp razor, or by raising 
the epidermis with a needle or with forceps, and cutting 
out a small portion with a sharp scalpel. The graft is 
next applied to the granulating surface with its raw sur- 
face in contact with the granulations ; after a sufficient 
number of grafts have been applied, a piece of sterilized 
protective is laid over them and is held in place by means 
of a few strips of isinglass plaster. A sterilized gauze 
dressing is next applied, and the dressing is not disturbed 
for a week or ten days, at which time, if the grafts have 
taken, isolated cicatrices at the points where the grafts 
were applied will be found. 

Thiersch's Method. — In skin-grafting according to this 
method, the surface of the ulcer is rendered aseptic, and 
all antiseptics are washed away with sterilized salt solu- 
tion. The surface of the ulcer is next curetted to remove 
soft granulations, and it is then irrigated and covered 
with protective, and a compress applied to control bleed- 
ing. Shavings of skin are then removed from a surface — 
which has been rendered aseptic — by means of a razor or 
section knife ; the use of MeBurney's hooks (Fig. 144) 
will facilitate the removal of the grafts. Each graft should 
be as long and broad as possible, and, when cut, it should 
be floated from the section knife upon the prepared surface 
of the ulcer by a stream of salt solution and gently pressed 
into place. After a sufficient number of grafts have been 



BONE-GRAFTING. 167 

applied, strips of protective are laid over the surface of 
the grafts, and over these is placed a compress moistened 
with salt solution and covered by protective, and a few- 
layers of sterilized gauze and cotton are next applied over 
this, and the dressing is held in position by a bandage. 

Fig. 144. 




McBurney's hook. 

The dressings need not be removed for a week or ten 
days, and a second dressing should be applied in the same 
manner until the grafts have become thoroughly vitalized. 
The skin of the bellies or backs of frogs, or the hairless 
skin of young animals may be used in place of human 
skin. 

Krause's Method. — Skin-grafting is sometimes accom- 
plished by immediately applying an isolated piece of skin 
to a raw surface to fill a gap ; the graft in such cases 
includes the whole thickness of the skin, but has all of 
the cellular tissue removed from it, and should be cut 
one-third larger than the gap to be filled, to allow for the 
shrinking after its removal, and is secured in position by 
sutures. 

Bone-grafting. — This procedure is resorted to to 
replace portions of bone which have been separated, to 
fill up cavities in bone, or to restore the continuity of the 
long bones. The bone to be introduced should be ren- 
dered thoroughly aseptic, and should be placed in a steril- 
ized salt solution at a temperature of 100° to 105° F.; it 



168 MINOR SURGERY. 

roay be inserted in one piece or broken into fragments and 
laid over the surface. 

When it is desired to restore the continuity of one of 
the long bones, after the surfaces of the bone have been 
exposed and rendered aseptic a bone is removed from a 
freshly killed animal, is rendered aseptic, and fitted into 
the gap and secured to the ends of the bone by sutures. 
Or a portion of the bone may be partially separated by a 
chisel and fitted into the gap, or is split into strips and 
packed into the cavity. 

In the case of parallel bones, such as the tibia and fibula, 
where there has been a loss in substance of the tibia, the 
fibula has been divided on a line with the lower end of the 
tibia, and after freshening the end of the tibia the upper 
end of the lower fragment of the fibula is shifted over to 
the tibia and secured to it by sutures. 

Bone-grafting may also be very satisfactorily accom- 
plished by means of Senn's decalcified bone plates or chips, 
which will be found useful in filling up the cavities result- 
ing from extensive removals of bone by injuries or in the 
operations for necrosis or caries. 

In such cases, after the cavity has been sterilized, it is 
dusted with iodoform and is then packed with bone chips ; 
iodoform is next dusted over them and they are covered 
by a piece of protective. A compress of iodoform or 
sterilized gauze and bichloride cotton is next applied, and 
the dressing is held in position by a bandage. 

When bone plates are employed, they are cut to fit the 
cavity, and provision should be made for drainage. 

Preparation of Decalcified Bone Chips or Plates. — Take 
sections of the compact tissue of the fresh tibia or femur 
of an ox, several inches in length, remove the periosteum 
and medullary tissue, split in pieces one-half an inch in 
width, and place them in a 15 per cent, watery solution 
of hydrochloric acid, allowing them to remain in this for 
three weeks, changing the solution daily. At the end of 
this time they should be removed, thoroughly w T ashed, and 
cut in thin strips or plates. They should then be washed 
in a weak solution of caustic potash, and placed for forty- 



GALVANO-CA UTERT. 169 

eight hours in a 1 : 1000 bichloride solution. After this 
they may be kept in a solution of iodoform in ether, or in 
a 1 : 500 solution of bichloride in alcohol until required 
for use ; before being used they should be soaked in saline 
solution or sterile water. 

Muscle-grafting and nerve-grafting are also occasion- 
ally resorted to, to supply deficiencies in muscles or 
nerves, fresh muscle or nerve tissue being employed to 
fill up the gap, but the results as a rule have not been 
satisfactory. 

Electrolysis. — Electrolysis, or the chemical decomposi- 
tion induced by electricity, is employed in surgery to de- 
stroy morbid products, tumors, or exudations. For this 
procedure, a galvanic or continuous-current battery is re- 
quired, which is provided with electrodes and needles of 
suitable shapes. In applying electrolysis to a tumor, for 
instance, the needle connected with one of the poles of the 
battery is inserted into the tumor, and the other rheophore 
is applied to the surface of the body, or two Hue needles, 
carefully insulated nearly to their extremities, are con- 
nected with both poles of the battery by conducting cords; 
these are introduced into the tumor and a weak current is 
allowed to pass. The strength of the current is gradually 
increased as the operation advances; the current is passed 
for fifteen or twenty minutes, and the procedure is repeated 
at intervals of several days until some decided change 
occurs in the tumor. 

Electrolysis has been applied with success in the treat- 
ment of aneurism inaccessible to other operative proced- 
ures, in malignant growths, in naevi, goitres, cysts, and 
hydatids. It is at the present time the most satisfactory 
method of removing superfluous hairs from those portions 
of the body in which their presence causes disfigurement. 

Galvano-cautery. — Galvano-cautery batteries are con- 
structed with plates of large size, placed closely together, 
so that the internal resistance is reduced and a current is 
quickly obtained which will keep a metallic electrode at a 
white heat. The advantage in the use of this form of 
cautery is that the electrode can be introduced into the 



170 



MINOR SURGERY. 



cavities of the body while cold and quickly heated to 
the desired temperature. The electrodes are made of 
various shapes aud sizes, according to the object desired 
(Fig. 145). The galvano-cautery is applied for the same 
purpose as the actual cautery ; but, as previously stated, 
its use is more convenient in the cavities of the body, 
its action can be more easily localized, and by its use 



Fig. 145. 




Electrodes for galvano-cautery. 

hemorrhage is avoided. It is frequently employed to 
destroy morbid growths in the nasal passages, the throat, 
vagina, or uterus, and also may be employed in the treat- 
ment of superficial external growths ; in using it for the 
removal of growths from the mucous membrane, its appli- 
cation may be rendered practically painless by previously 
thoroughly cocainizing the parts. 

Faradization. — The application of electricity in this 
form is often employed in surgical affections ; in cases of 
wasting of the muscles following fractures or sprains, in 
some forms of club-foot, and in lateral curvature of the 
spine the judicious use of the faradic current will often be 
found to be followed by the most satisfactory results. The 
current is applied in such a manner as to bring about 
contraction of the affected or wasted muscles, and thus 
improve their nutrition. 

Franklinization. — The earliest application of electricity 
in the treatment of disease was in the form of statical 
electricity, and although it fell into disuse, it has recently, 
with the perfection of modern machines, been widely re- 
vived. In applying statical electricity the patient may 
be treated by insulation, or the so-called dry electric bath. 



THE CYSTOSCOPE. 



171 



The second method of using statical electricity is by sparks 
or shocks from a Leyden jar. which is charged from the 
prime conductor of an electrical machine in motion, or by 
the electric brush. McClure states that in the static 
induced current we have a means of producing muscular 
contractions when failure results from the strongest faradic 
currents that can be borne by the patient. 

The Cystoscope. — This is an instrument employed for 
ocular examination of the walls of the bladder, and is one 
of the most important and useful of the electric-lamp 



Fig. 146. 




Illumination o 



all of bladder by cystoscope. Tap.k.1 



instrument-. A cystoscope consists of a beaked sound in 
which there is a telescopic arrangement, by which the inner 
surface of the bladder is viewed through a -mall window 
of rock crystal. The lamp is enclosed in the beak of the 
instrument and throws its light through another window, 
also of crystal, upon any part of the bladder wall. The 
bladder should contain six or eight ounces of clear urine 
or clear water if a proper view of the walls is to be ob- 
tained. If the fluid is turbid or contains blood, the view 
is very much obscured : if too little fluid be present in the 



172 



MINOR SURGERY. 



bladder, the beak of the instrument containing the lamp 
is likely to become buried in the folds of mucous mem- 
brane and the light will be cut off, and the mucous mem- 
brane may be burned. The bladder may be emptied of 
urine and distended with air which accomplishes the same 
purpose. A certain amount of practice is required to use 
the cystoscope properly and to recognize the appearance 

Fig. 147. 




The urethroscope. 

of the mucous membrane of the bladder in health and in 
its varied morbid conditions (Fig. 146). 

The Urethroscope. — The urethroscope consists of a 
straight metal tube provided with an obturator of hard 
rubber, which projects slightly beyond the end of the tube. 
This tube is introduced into the urethra until the bladder 
is reached, when it is slightly withdrawn and the obturator 
removed. The instrument is then attached to the mirror 
of an electric lamp, by which a strong light is thrown into 
the tube, and as the tube is withdrawn the urethra is ex- 
posed to view. By means of the urethroscope a very 
accurate inspection of all portions of the urethra can be 
obtained (Fig. 147). 

The Panelectroscope.— This instrument, introduced 
by Leiter, consists of an electric lantern, with tubes and a 



MASSAGE. 173 

mirror. The light from a small incandescent lamp is 
projected by the mirror along the tube, which is inserted 
into the part to be examined. Tubes of various sizes are 
adapted to the instrument. It is employed for endoscopy 
of the urethra, ear, pharynx, and stomach. 

MASSAGE. 

Massage consists in a variety of manipulations, such 
as pinching up the integument and muscles, and rolling 
them between the thumb and fingers ; in stroking or rub- 
bing the surface with the palm of the hand from the 
periphery toward the centre, to empty the distended veins 
and lymphatics ; rubbing the parts circularly with the 
extremities of the fingers and thumbs or the palms of 
the hands. Kneading of the parts is another method of 
practising massage. Massage may also be .practised by 
tapping the surface of the affected part more or less forci- 
bly with the tips of the fingers held in a row, or with 
the ulnar border of the hand or the palm of the hand. 
Before applying massage to an affected part, if there be a 
heavy growth of hair, it should be shaved off; otherwise 
the manipulation may give the patient pain, and irritation 
of the hair-follicles resulting in abscesses will be apt to 
occur. The part should also be robbed over with olive 
oil, vaseline, or cacao-butter before and during the manip- 
ulations. 

Massage is employed often with advantage in the treat- 
ment of sprains and strains in their subacute and chronic 
stages. Lueas-Championniere advocate- and praetises 
immediate and continuous massage in the treatment of 
fractures. It will also be found of great service in the 
later treatment of fractures involving the joints or their 
vicinity, in restoring the motion of the parts as well a- in 
improving the nutrition of muscles which have become 
wasted from disuse. 

Passive Motion. — This manipulation consists in alter- 
nately flexing and extending or rotating the limb, to imi- 



174 MINOR SURGERY. 

tate the normal joint-movements. The motions should be 
carefully practised, and in cases of fracture they should not 
be undertaken, as a rule, until there is firm union at the 
seat of fracture ; if for any reason passive motion is made 
use of before this time, the fragments should be firmly 
supported while it is being employed. Other forms of 
massage, such as stroking and kneading, may be employed 
in conjunction with passive motion in the treatment of the 
stiffness of joints resulting from fractures, dislocations, 
and sprains ; passive motion applied in this manner will 
often restore the function of a stiff joint more satisfac- 
torily and with less pain to the patient than the forcible 
manipulations which are sometimes practised under an 
anaesthetic. 

Compression. — This is a valuable means of dimin- 
ishing swelling in the early stages of inflammation, and 
of bringing about absorption of the effusion in the later 
stages. It may be applied by means of compresses, 
bandages, or strapping. Pressure applied in this manner 
is often employed in the treatment of injuries of the 
joints and bursa?, and in chronic inflammatory swellings. 
It should be used with caution when the circulation in 
the tissues is impaired. 

Application of Hot Air. — The employment of a con- 
tinuous hot-air bath has recently been advocated in the 
treatment of painful and partially anchylosed joints, 
synovitis, teno-synovitis, and chronic rheumatism. In 
applying this method of treatment, the limb is wrapped 
loosely in lint and introduced into a metallic cylinder 
(Fig. 148), the temperature of which is raised to about 
300° F. The part is exposed to this temperature for 
three-quarters of an hour to one hour, and at intervals 
of twenty minutes the door is opened for a short time to 
allow the ingress of fresh air; if the part is perspiring, 
it is wiped dry, for if moisture is present upon the limb 
burns are likely to result. Under this form of treat- 
ment pain is often temporarily or permanently relieved, 
synovial effusions absorbed, and adhesions are softened 
and disappear. Clinically it has been found that the best 



THE CLINICAL THERMOMETER. 



175 



results following this method of treatment have occurred 
in painful and anchylosed joints following traumatisms ; 
and although temporary improvement has occurred in 
rheumatic, gouty, tuberculous, and gonorrheal affections 
of joints, permanent improvement is not so likely to 
result. 
The Clinical Thermometer. — For clinical observa- 



Ftg. 148. 




Apparatus for hot-air treatment. 

tions two thermometer scales are in general use, the centi- 
grade and the Fahrenheit; the latter is the one commonly 
employed in America and in England. Thi> scale has a 
limited range above and below the normal bodily tem- 
perature, which is 98.4° Fahrenheit or 36° centigrade. 
Thermometers are now made with a convex surface, which 
serves to magnify the column of mercury, and thus 



176 



MINOR SVRGERY. 



enables the observer without difficulty to note the position 
of the index (Fig. 149). 

The temperature of the body may be taken in the 
mouth, axilla, vagina, or rectum ; the two former loca- 



Fig. 149. 



Ficx. 150. 



Clinical thermometer. 



Surface thermometer. 



tions are those generally selected. When taken in the 
axilla, care should be exercised to see that no clothing is 
interposed between the skin and the instrument ; and 



SKIAGRAPHY. 



Ill 



when the mouth is used for thermometric observations the 
patient should be instructed to keep his lips tightly closed 
and breathe through his nose. The thermometer should 
be kept in place for from three to five minutes. 

Surface thermometers are sometimes employed, the 
instruments for this purpose having bulbs of a discoid 
shape (Fig. 150), or being drawn out in the form of a 
spiral or coil. In using this form of thermometer to de- 
termine the amount of variation of the surface tempera- 

Fig. 151. 




1 



Apparatus for taking skiagraphs. (Park.) 

ture, the temperature of corresponding parts of the body 
on the opposite side and the general temperature of the 
body should be taken at the same time. 



SKIAGRAPHY, OR EMPLOYMENT OF THE RONTGEN 

RAYS. 

Rontgen, in 1895, while investigating the cathode rays 
as developed in Crookes's tubes, discovered the energv 
which lie named .r-ravs. The rays are invisible, but have 

12 



178 



MINOR SURGERY. 



great power of penetration, and pass through many sub- 
stances which are opaque to sunlight and ordinary electric 
light. If the rays are intercepted by a body not readily 
permeable, which is placed between the Crookes's tube and 



Fig. 152. 




Skiagraph of fracture of the lower end of the radius. (Newcomet.) 



a dry photographic plate, a shadow will be formed, and an 
impression of this shadow will be formed upon the plate. 
Such a shadow is known as a skiagraph. The fluoroscope 
consists of a fluorescent screen, which is so placed that 



SKIAGRAPHY. 



179 



the rays emanating from the Crookes's tube and passing 
through any intercepted substance to be studied are re- 
flected directly upon it. If the body is more or less 
resistant, the observer can see it clearly through the skin 
and subcutaneous tissue. 



Fig. 153. 




Skiagraph of bullet in wrist-joint. (Newcomet.) 



The time of exposure to the rays varies with the 
strength of the current and the thickness of the tissues. 
The exposure is usually from three to fifteen minutes. 
The tube should not be placed too near the surface 



180 



MINOR SURGERY. 



of the body, and the exposure should be as short as 
possible. 

There occasionally develops after the use of the arrays 
a peculiar disturbance of the tissues, probably trophic in 



Fig. 154. 




Skiagraph of fracture of tibia and fibula. 



nature, which is known as an a>ray burn. The skin, 
several weeks after exposure to the rays, may become 
ulcerated, the nails may be lost, and a very intractable 
form of ulceration or gangrene develop. 



SKIAGRAPHY. 



181 



The rr-rays are of great value in locating foreign 
bodies, such as needles, pins, bullets, and pieces of 
glass. They are employed also with advantage in locat- 
ing mineral calculi in the bladder, ureter, and kidney. 
They are also useful in detecting the presence of frae- 



Fig. 155. 




Multiple fracture of patella. (Newcomet.) 



tures and dislocations. In fractures about the joints, 
epiphyseal separations, and ununited fractures, their use 
has proved most satisfactory. Very satisfactory results 
have recently been obtained in the treatment of super- 
ficial malignant growths and lupus and inoperable forms 



182 



MINOR SURGERY. 



of carcinoma and sarcoma by frequent short expos- 
ures to the arrays. Skiagraphs of fractures are shown 
in Figs. 152, 154, and 155 ; of a bullet in the wrist-joint in 



Fig. 156. 




Skiagraph of separation of upper epiphysis of the humerus. 

Fig. 153 ; and of an epiphyseal separation of the humerus 
in Fig. 156. 



ANESTHETICS. 

Anaesthesia may be local, regional, or general. 
Local Anaesthesia. — This results from the direct appli- 
cation of anaesthetic agents to nerve-terminations, and 



ANESTHETICS. 183 

causes analgesia of the tissues to a limited extent only. 
It may be produced by the use of cold, a spray of ether, 
rhigolene, ethyl chloride, or kelene, cocaine or eucaine 
hydrochlorate, holocaine hydrochlorate, guaiacol, or by 
Schleich's method of infiltration. 

Regional Anaesthesia. — This is also sometimes described 
as neural anaesthesia, and results from the application of 
anaesthetic agents to the nerve-roots, nerve-trunks, or the 
spinal cord. The analgesia in this form of anaesthesia 
extends from the point of application to the tissues sup- 
plied by the nerve or nerves, and therefore is not limited 
in extent. 

General Anaesthesia. — This is characterized by un- 
consciousness, as well as abolition of sensation, and may 
be induced by the administration of nitrous oxide gas, 
ether, chloroform, bromide of ethyl, chloride of ethyl or 
kelene A.-C.-E. mixture, Schleich's anaesthetic mixture, or 
scopolamine. It may also be induced by a combination of 
these substances with nitrous oxide gas or oxygen. Hypno- 
tism may also be employed to produce general anaesthesia. 



Local Anaesthesia. 

Cold. — Local anaesthesia may be produced by the ap- 
plication of cold, or freezing mixtures, either by a 
piece of ice or a mixture of ice and salt held in con- 
tact with the part for one or two minutes, or by direct- 
ing a spray of rhigolene or sulphuric ether upon the 
surface of the part whose sensibilitv is to be obtunded 
(Fur. 157). 

Chloride of Ethyl or Kelene.— This substance is used 
also to produce local anaesthesia, and is convenientlv fur- 
nished in glass tubes, one end of which is drawn out into 
a fine point and hermetically sealed. When used, the end 
of the tube is broken off and a fine jet of ethyl is projected 
upon the part to be anaesthetized, the warmth of the hand 
being sufficient to force the fluid from the tube. This form 
of local anaesthesia is made use of in minor surgical pro- 



184 MINOR SURGERY. 

cedures, such as aspiration, the opening of abscesses, and 
the removal of superficial tumors. 

The objection to these methods of anaesthesia consists 
in the pain which accompanies the thawing process, and 
the interference with the vitality of the tissues by the 
freezing, which prevents prompt healing. 

Rapid Respiration. — Rapidly repeated deep inspira- 
tions kept up for a few minutes will produce insensibility 
to pain, but sensibility to contact is not obliterated. This 
form of anaesthesia may be made use of in a slight opera- 
tion, such as opening an abscess. 

Fig. 157. 




Application of rhigolene spray. 

Cocaine. — Local anaesthesia produced by the employ- 
ment of an aqueous solution of the hydrochlorate of 
cocaine, in strength from 1 to 2 per cent., is often made 
use of in minor surgical procedures. Solutions as strong 
as 10 or 12 per cent, were formerly employed, but experi- 
ence has proved that there is always danger in the use 
of the stronger solutions of cocaine, so that it is now con- 
sidered wise not to use one stronger than 1 or 2 per cent., 
as the full analgesic effect can be obtained by a solution 
of this strength. When mucous membrane is to be oper- 
ated upon or growths removed from it, analgesia is pro- 
duced by brushing over the surface with the solution of 
cocaine, or by applying to the part for a few minutes a 
compress of absorbent cotton saturated with it; in mucous 



ANESTHETICS. 185 

cavities the latter method of application will be found 
most convenient. In using a solution of cocaine to pro- 
duce anaesthesia in operations upon the eye, a 2 per cent, 
solution is dropped into the eye, and is repeated until 
analgesia is complete. 

In applying cocaine to the urethra, a 1 to 2 per cent, 
solution is injected, and is allowed to remain for two or 
three minutes ; more than 1 or 2 grains should not be 
injected at one time, as fatal results have followed the 
injection of larger quantities ; this is especially the case 
in using cocaine in the urethra and the rectum, and in 
these situations great caution should be exercised in its 
employment. 

When it is desired to produce local anaesthesia of the 
skin or deeper tissues, the application of cocaine to the 
surface is not satisfactory, and it should in sueh cases be 
injected hypodermically into the deeper layers of the skin 
and into the cellular tissue of the part- to be operated 
upon; to avoid multiple punctures, the needle is not com- 
pletely withdrawn from the wound, but its direction is 
changed and the solution is thrown into different portions 
of the tissues. It is well, in situations where it can be 
accomplished, to cut off the circulation from the part to 
be operated upon by placing around it a rubber strap or 
tube, which prevents rapid absorption of the cocaine into 
the general blood-current. 

Corning recommends injection of cocaine by the gal- 
vanic current. 

Some persons have an idiosyncrasy for cocaine, and 
children seem more susceptible to its constitutional effects 
than adults. I have seen several instances in children in 
which marked symptoms of cocaine poisoning resulted 
from the application of a I per cent, solution to the nasal 
mucous membrane. 

The treatment of cocaine poisoning consists in placing 
the patient in the recumbent position and the hypodermic 
injection of morphine, strychnine, or ether. 

Cocaine ancvstliesia may be employed with advantage 
in minor surgical operations, such as amputations of the 



186 MINOR SURGERY. 

fingers, circumcision, opening of abscesses, and removal 
of superficial tumors, but its utility is most marked in 
operations upon the eye and upon the mucous membranes 
of the nose, throat, rectum, vagina, and urethra. Applied 
for a few minutes to the surface of an ulcer which is to 
be cauterized, it will render the operation almost painless. 

Eucaine Hydrochlorate. — This drug, which possesses 
the same properties as cocaine, as regards the production 
of analgesia, is employed as a local application to mucous 
surfaces, and hypodermically in the deeper tissues to pro- 
duce local and regional anaesthesia. It has the advantage 
over cocaine that it can be used with safety in much larger 
quantities, as it is apparently free from toxic action. 
Kiessel states that 2 grammes have been injected without 
the production of toxic symptoms. It may be used in 
solutions varying in strength from 2 to 10 per cent., 
which may be sterilized by heating ; a 2 per cent, solution 
is that most usually employed hypodermically. 

Holocaine Hydrochlorate.— This drug/ used in a 1 
per cent, solution, possesses as decided analgesic action as 
cocaine ; it is also strongly bactericidal in its action. It 
may be used locally without producing constitutional 
symptoms, but cannot be used internally or injected into 
the tissues, on account of its marked toxic action. 

Guaiacol. — This drug may be used for its analgesic 
effect, and is employed in a solution of guaiacol, grains 
xv ; alcohol, 3v ; or in the form of an ointment of guaiacol, 
5 parts, to vaseline, 30 parts ; or it may be used hypoder- 
mically in a one-tenth or one-twentieth solution in olive 
oil. Its hypodermic use is not unattended with danger. 

Infiltration Anaesthesia. — It has been shown by Lie- 
breich that the injection of simple water into the tissues 
in such a way as to produce an artificial oedema induces 
a transitory anaesthesia. 

Schleich found that the combination of a minute quan- 
tity of cocaine and morphine with a weak salt solution, 
when injected hypodermically, produced a local anaesthesia 
of longer duration. 

The anaesthesia is produced by the artificial ischaemia, 



ANAESTHETICS. 187 

by the pressure of the injected fluids upon the nerves, and 
by the direct action of the anaesthetic substances on the 
nerves. 

A solution of 1 part of cocaine to 1000 parts of steril- 
ized water may be used, or the following solution may be 
employed : 

Cocaine hydrochlor. gr. iss. 

Morphise hydrochlor gr. J. 

Sodii chloridi gr. iij. 

Aquse dest ^iijss. 

The injection should first be made into the substance of 
the skin itself, and then into the cellular tissues and deeper 
structures, as desired. 

Infiltration anaesthesia has been widely employed in 
minor surgical operations, and also may be employed in 
major operations, such as herniotomy and amputations, 
when for any reason a general anaesthesia is not desirable. 
In children and nervous subjects it cannot be employed 
with advantage. It also has the disadvantage of causing 
swelling and oedema of the tissues at the scat of operation, 
which often interfere with the satisfactory recognition of 
the various anatomical structures. 



Regional Anaesthesia. 

This method, sometimes described as neural anaesthesia, 
consists in bringing anaesthetic drugs in contact with 
nerve-trunks at some distance from the field of opera- 
tion, with the view of causing analgesia in the tissues 
supplied by them. For instance, in a proposed operation 
upon the leg, the injection would be made near or into 
the anterior crural and sciatic nerves. Cocaine, eucaine, 
or Schleich/s solution may be employed for the pur- 
pose. The nerves may be anaesthetized by the paraneural 
method, which consists in injecting the solution in the 
vicinity of the nerve-trunk as near as possible to the 
nerve ; or by the direct intraneural method, which con- 
sists in producing anaesthesia of the skin and cellular 



188 MINOR SURGERY. 

tissue, and then exposing the nerve-trunks by dissection 
and injecting the solution directly into them by passing 
the needle into their substance. 

This method of anaesthesia has been employed with 
success both in minor and major surgical operations, such 
as the reduction of herniae, amputations, and the removal 
of tumors, and is especially applicable in operations upon 
the extremities. 

Spinal Subarachnoid Injection. — As the result of the 
work of Corning, Bier, and Tuffier, anaesthesia by means 
of spinal subarachnoid injection of cocaine or eucaine has 
recently been employed with satisfactory results. At the 
present time this method of anaesthesia is resorted to only 
in operations upon that portion of the body below the 
diaphragm, and injections are made into the spinal canal 
in the lumbar region. Fifteen to 20 minims of a 2 per 
cent, cocaine or eucaine solution are usually sufficient to 
produce satisfactory anaesthesia. The technique of the 
operation is as follows : The entire lumbar and sacral 
regions should carefully be sterilized, and the position of 
the third lumbar interspace — that is, the space between 
the third and fourth lumbar vertebrae — located. The 
patient next sits astride of the operating-table and bends 
forward in the position of ventral flexion, with his elbows 
resting upon his knees, which widens the space between 
the third and fourth lumbar vertebrae. A few drops of 
cocaine or eucaine are next injected into the skin over the 
centre of this space. A needle between 1 and 2 milli- 
metres in circumference, and about 8 centimetres in length, 
attached to a syringe, is next inserted through the skin mid- 
way between the spinous processes, or a puncture by a 
tenotome may be made through the skin, and the needle 
inserted through this. The needle and syringe should be 
thoroughly sterilized by boiling before being used. The 
needle should be pushed forward and a little to the left, 
to cause it to enter the spinal canal in the median line, 
and as soon as resistance disappears and fluid appears in 
the syringe it is evident that the canal has been entered. 
After a few drops of fluid have escaped, the syringe is 



ANESTHETICS. 189 

removed from the needle and replaced by one containing 
the anaesthetic solution, and 15 to 20 minims of the solu- 
tion are injected into the spinal canal. The needle is then 
removed and the puncture sealed with a small piece of 
gauze and collodion, and the patient placed in the recum- 
bent posture. In a few minutes anaesthesia is usually 
sufficiently advanced for the operation. 

Subarachnoid spinal injection should not be employed 
in children, nor in nervous and excitable patients, but 
may be employed in cases where for any cause a general 
anaesthetic is contraindicated. 

This method of anaesthesia has been employed success- 
fully in a great variety of operations, and up to the 
present time few fatalities have been reported as the re- 
sult of its use ; but it should be remembered that the pro- 
cedure is still on trial, and that sufficient time has not 
elapsed to show the ultimate result of the injections. A 
more extended use of the method alone can prove that it 
is safer than the general anaesthetics now employed. The 
restriction in its use to operations in certain parts of the 
body also renders it difficult to estimate its comparative 
safety. 

General Anaesthesia. 

General anaesthesia may be produced by the adminis- 
tration of nitrous oxide gas, ether, chloroform, A.-C.-E. 
mixture, Schleich's mixture, ethyl bromide, ethyl chloride 
or kelene, or scopolamine hydrobromate. 

Choice of Anaesthetic. — In selecting an anaesthetic, the 
most important considerations are its safety and its suita- 
bility to the individual case. In point of safety, nitrous 
oxide gas holds the first place ; but, unfortunately, its use 
is restricted to cases in which only a few minutes' anaes- 
thesia is required. Statistics show that the mortality fol- 
lowing the administration of nitrous oxide is about 1 to 
5,250,000 ; of ether, 1 to 16,675 ; of chloroform, 1 to 
3749. Gardner's statistics show that in 22,219 chloro- 
form administrations there were 14 deaths ; while in 
17,067 administrations of ether or nitrous oxide gas and 



190 MIX OR SURGERY. 

ether, there was 1 death. It should be remembered, how- 
ever, that both ether and chloroform are employed in the 
most serious surgical procedures, while nitrous oxide gas 
is used only in trivial operations, so that many of the 
deaths attributed to ether and chloroform may have been 
due to conditions resulting from the operations. General 
anaesthesia seems to be accompanied by especial danger in 
subjects presenting the condition known as the status lym- 
phaticus. 

Nitrous Oxide Gas. — Xitrous oxide causes anaesthesia 
by arresting the oxygenation of the blood while it is in 
contact with it, and, in addition, the gas produces anaes- 
thesia by direct action on the cerebral cortex. Citrous 
oxide gas is contraindicated in alcoholic subjects, or in 
those having marked atheroma of the arteries, as apoplexy 
may occur, or in any condition of obstructed respiration. 
The apparatus best suited for its administration consists 
of a cylinder of metal in which the gas is compressed, 
which is attached to a rubber bag, Avhich has a mouth- 
piece fastened to it ; this is provided with a double valve, 
which prevents the expired air from passing back into 
the bag. The mouthpiece is adjusted over the mouth, 
and after removing any false teeth or foreign bodies from 
the mouth, the patient is instructed to take deep, full 
breaths, and in from one-half to one minute the face 
becomes congested and dusky and the breathing becomes 
stertorous, indicating that the patient is fully under the 
influence of the gas. The anaesthesia from nitrous oxide 
cannot be prolonged for more than a few minutes, so 
that it can only be employed in operations which take a 
short time for their performance, such as the extraction 
of teeth and the opening of abscesses. Unfortunately, it 
cannot be used in the reduction of fractures or disloca- 
tions, as it does not produce complete muscular relaxation. 
In England nitrous oxide is frequently used to produce 
anaesthesia, and when this result is accomplished the anaes- 
thesia is kept up by the administration of ether by the 
employment of a special apparatus devised for this pur- 
pose. Nitrous oxide gas is commonly employed in dental 



ANESTHETICS. 191 

surgery to produce anaesthesia for the removal of teeth, 
but is also occasionally employed in minor surgical opera- 
tions; but from the fact that the apparatus for its ad- 
ministration is a bulky one, its use is not so convenient as 
ether or chloroform. 

Nitrous oxide gas may also be administered by the open 
method, or by an open inhaler resembling that of Allis. 
The gas, being heavier than the air, is introduced into the 
inhaler and falls to the bottom. Flux, who has employed 
this method of administration in a number of cases, claims 
that by its employment excitement, stertor, lividity, strug- 
gling, and convulsive movements are done away with. 

Nitrous Oxide Gas and Oxygen. — The administration 
of nitrous oxide gas with oxygen has been found by Hewitt 
to diminish the asphyxial symptoms, so that a more pro- 
longed and tranquil amesthesia can be safely obtained. The 
anesthetic state is not produced as rapidly as by nitrous 
oxide gas alone, but it may be prolonged by a skilful 
amesthetizer for an hour or more. It is administered by 
a special apparatus, by which the administrator can increase 
or diminish the amount of oxygen, according to the symp- 
toms presented. Cyanosis, stertor, and muscular twitching 
call for an increase in the oxygen, whereas symptoms of 
excitement call for its diminution. In children and in 
aged and anaemic subjects the amount of oxygen may be 
increased rapidly ; whereas in strong, full-blooded subjects 
the quantity of oxygen should be increased cautiously. 

Ether. — Sulphuric ether is one of the most widely em- 
ployed substances in surgery to produce anaesthesia ; it is 
probably the safest of all anaesthetics, except nitrous oxide 
gas, and for this reason should be preferred to all others. 
Its effects, according to Hare, result from the action of the 
drug, first, on the brain, then on the sensory tracts of the 
spinal cord, then on the motor tracts, then on the sensory 
side of the medulla oblongata, and finally upon the motor 
side of the medulla, and thereby produces death from res- 
piratory failure if given to excess. Its administration is 
attended with risk in the following cases: (1) In infants, 
in whom it causes irritation of the bronchial mucous mem- 



192 MINOR SURGERY. 

brane, with profuse secretion of mucus, and may cause also 
bronchopneumonia. (2) In aged persons a profuse secre- 
tion of mucus and bronchopneumonia may follow its use ; 
it is also contraindicated in these subjects in whom there 
are rigidity of the chest and lessened respiratory power. 
(3) In advanced organic disease of the kidneys, and 
especially in nephritis of the interstitial form with urine 
of a low specific gravity and in diabetic subjects. (4) In 
disease of the heart its administration is more dangerous 
in myocardial than in valvular lesions. (5) In cases of 
obstructed respiration from swelling of the pharynx, fixa- 
tion of the tongue in cancer and cellulitis of the neck, and 
in emphysema and abdominal distention. (6) In cases in 
which examination of the blood shows that the haemoglobin 
is diminished to less than 50 per cent. (7) AVhen the 
bronchial irritation following its use may impair the re- 
sult in operations for hernia and in laparotomy. 

Preparation of Patient. — A patient should be prepared 
for the administration of ether by withholding all solid 
food for at least six hours before its inhalation ; he should 
be in the recumbent posture, and any garments about the 
chest or neck should be loosened, so that the respiratory 
movements are not interfered with. The surgeon should 
see also that any false teeth or foreign bodies which may 
be present in the mouth are removed before the adminis- 
tration of the drug is begun. As the vapor of ether 
often causes irritation of the mucous membrane of the 
lips and nasal passages, it is well to anoint these parts 
with a little vaseline or cold-cream before administering 
the ether. 

The stomach, if it contains food, should be washed 
out by means of the stomach-pump. This washing 
out of the stomach, before operation in cases of intesti- 
nal obstruction, is of the greatest importance, as the 
stomach may contain stercoraceous matter, which may be 
drawn into the respiratory passages if vomiting occurs, 
and produce death by suffocation or later cause aspiration- 
pneumonia. 

It should also be borne in mind that the vapor of ether 



ANESTHETICS. 193 

is very inflammable, and that it is heavier than the air, so 
that lights brought near the patient while being etherized 
should be held at a higher level than the ether-can or 
inhaler. 

The anaesthetizer should always listen to the patient's 
heart before giving an anaesthetic ; this enables him to 
detect any irregularity in its action, and at the same time 
has a good moral effect upon the patient, especially if he 
can assure him that he is in good condition to take the 
anaesthetic. 

It is well also to have another physician present during 
the administration of a general anaesthetic, as unforeseen 
difficulties occasionally arise. There should always be at 
hand tongue-forceps and instruments with which trache- 
otomy may be performed if necessary ; also nitrite of amy], 
digitalis, strychnine, and a hypodermic syringe. 

In debilitated patients or in those who are weak from 
loss of blood the administration of half an ounce to an 
ounce of whiskey from fifteen to thirty minutes before the 
anaesthetic is given is often advisable. 

The person intrusted with the administration of the 
anaesthetic should watch the patient closely, and should not 
have his attention diverted by the operation ; he should 
carefully observe the pulse, respiration, and color of the 
patient's face, and be prepared to withdraw the anaesthetic 
upon the development of any symptom of danger, and to 
treat such symptoms should they arise. 

The anaesthetizer should be careful that no ether comes 
in contact with the conjunctiva, as severe ether conjunctivitis 
has resulted from this accident. He should also be care- 
ful in testing; the sensibilitv of the cornea not to touch it 
with the finger, but should press upon it through the eye- 
lid, for infection of the cornea, resulting in sloughing, has 
resulted from neglect of this precaution. 

An anaesthetic should never be given to a woman with- 
out the presence of a third person, as in some cases these 
agents give rise to erotic dreams, and it may be difficult 
to disabuse the patient's mind of the idea that an assault 
has been committed unless the evidence of eve-Avitnesses 

13 



194 



MINOR SURGERY. 



at the time of the anesthetization can be brought forward 
to prove that such was not the case. 

Ether produces more irritation of the respiratory tract 
than chloroform, and its administration is sometimes fol- 
lowed by the development of bronchitis, pulmonary con- 
gestion, or pneumonia. These complications are less likely 
to occur if care is taken to avoid the administration of 
ether in patients who are suffering from bronchial irrita- 
tion, and to see that a patient who has taken ether is not 
exposed to draughts and is not allowed to go out into 
cold or moist air immediately after recovering from the 
anaesthetic. 

Administration of Ether. — In the administration of ether, 
a towel folded into a cone or one of the various ether 

inhalers may be employed. 
Fig. 158. The best of these is Allis's 

inhaler, which consists of a 
metallic framework covered 
with leather or a nickel- 
plated case, which carries a 
number of folds of a roller- 
bandage, giving a large sur- 
face for the rapid evapora- 
tion of the drug (Fig. 158). 
If a towel folded into a 
cone is used ; a few layers of 
stiff paper interposed between 
the outer layers of the towel 
will keep the cone in shape 
and prevent evaporation of 
the ether from its external surface. 

For the administration of an anaesthetic, the patient 
should be in the recumbent posture and the head turned 
to one side, as in this position mucus is less apt to collect 
in the pharynx and interfere with the breathing. 

In administering ether, two to four drachms are poured 
into a cone or inhaler and placed over the nose and mouth 
of the patient. He is then requested to take deep breaths, 
or to blow the ether away, which latter procedure causes 




Allis's ether inhaler. 



ANAESTHETICS. 195 

him to take deep inspirations. In the beginning of ether- 
ization the patient will resist the inhalation much less 
vigorously if the ether is given slowly with a plentiful ad- 
mixture of air. The first effect of the inhalation of ether 
is to produce acceleration of the pulse and respiration ; the 
mucous membrane of the air-passages is irritated, and 
coughing often occurs ; there is also in this stage a dispo- 
sition to muscular movements, and it is frequently neces- 
sary to restrain the patient ; the brain also is excited, and 
the patient is apt to cry out. These symptoms call for a 
continuance of the administration of the ether, and not for 
its withdrawal. Succeeding the stage of excitement, if 
the ether be pushed, profound anaesthesia takes place, as 
is evidenced by the loss of consciousness, relaxation of 
the muscular system, moist skin, loss of special senses, 
contracted pupils, and slow and deep respiration, tend- 
ing to become stertorous. When the conjunctiva is in- 
sensitive to the touch of the finger, anaesthesia is usually 
profound. When the anaesthesia is complete, the amount 
of ether inhaled should be diminished, and the patient 
given only so much as will keep him well under its influ- 
ence. It is surprising how small a quantity a careful 
and watchful anaesthetizer will require to keep the patient 
fully under its effects for a considerable time. The time 
required to produce anaesthesia varies in different cases : 
it. is produced in children in a few minutes ; in adults 
from ten to twenty minutes are usually required ; drunk- 
ards and those who have taken ether frequently require 
a larger amount and a longer time to come under its in- 
fluence. After the administration of the drug is stopped, 
the patient may continue for some time in an unconscious 
condition, resembling a quiet sleep, or he may awake and 
exhibit more or less symptoms of cerebral excitement. 

First Insensibility from Ether. — There often exists in 
the early course of the administration of ether a stage of 
primary anaesthesia, which lasts for a minute or more, 
and which may be taken advantage of to perform such a 
minor surgical operation as opening an abscess, reduction 
of a dislocation or a fracture, or extraction of a tooth. 



196 MINOR SURGERY. 

The recovery from this condition is usually very prompt, 
and is not followed by nausea or the after-effects which 
attend the prolonged administration of ether. 

Accidents during Etherization. — During the administra- 
tion of ether, particularly in the early stage, the patient 
may suddenly stop breathing, the face at the same time 
becoming cyanosed. This condition calls for withdrawal 
of the ether ; and if an inspiratory effort does not quickly 
follow, pressure should be made upon the front of the 
chest, and when this is relaxed a deep inspiration usually 
takes place, and no further difficulty is experienced. This 
condition should not be confounded with the very common 
effort of holding the breath, the latter occurring with the 
chest fully expanded, the former with the chest empty. 

Vomiting may occur during etherization, and the vom- 
ited matter may accumulate in the pharynx or the mouth, 
and obstruct the breathing, or may enter the larynx or 
trachea and cause a like result. Vomiting is more apt to 
take place if solid food has been taken shortly before the 
administration of the anaesthetic. If this accident occurs 
and interferes w T ith breathing, the jaws should be opened 
and the head turned to one side, when the vomited matter 
will usually escape without difficulty. If, however, food 
has entered the larynx, and is not ejected by coughing, it 
will be necessary to perform tracheotomy promptly and 
hold the tracheal wound open, or to introduce a tube and 
practise artificial respiration. The breathing may also be 
obstructed by the accumulation of mucus and saliva in 
the pharynx. This is less likely to occur if the head is 
kept to one side during the administration of the drug; 
if it occurs, the head should be turned to one side, the 
jaws opened, and the material removed with small sponges 
or pieces of gauze fixed to sponge-holders. 

The tongue may fall backward and obstruct the breath- 
ing when muscular relaxation is complete during anaesthe- 
sia ; this accident is also less likely to occur if the head 
is kept to one side during etherization. If asphyxia 
results from falling back of the tongue, it should be 
brought forward by placing the fingers on each side 



ANMSTHETTCS. 197 

beneath the angles of the inferior maxillary bone, and 
pushing the jaw forward, at the same time over-extending 
the neck by bending the head backward (Fig. 159), or the 
mouth should be opened and the tongue drawn forward 
with tongue forceps. Either of these manipulations is 
usually sufficient to re-establish the respiratory movements. 

If, however, in any of these forms of mechanical asphyxia 
respiratory action is not promptly restored, some form of 
artificial respi ration should promptly be resorted to, either 
Laborde's, Silvester's Howard's, or forced respiration ; and 
of these, Laborde's method, by rhythmical traction of the 
tongue, and Silvester's have yielded the most satisfactory 
results. Eiforts at resuscitation in these cases should 
be persevered in for at least half an hour, as apparently 
hopeless cases have been saved by persistent use of these 
means. 

Failure of respiration may occur also from paralysis of 




Pushing the jaw forward. 

the respiratory centres, or spasm of the respiratory 
muscles ; the former may occur from an overdose of the 
anaesthetic, or from intercurrent asphyxia, syncope, or 
morbid states of the respiratory system. 

Spasmodic respiratory failure may occur before complete 
anaesthesia, and is liable to arise in muscular and emphy- 
sematous subjects. Respiratory failure from either of 



198 MINOR SURGERY. 

these causes should promptly be treated by artificial respi- 
ration and the hypodermic use of strychnine, atropine, or 
digitalis. 

After-effects of Ether. — After complete anaesthesia from 
ether, nausea and vomiting are very common, and both are 
more apt to follow in case the patient has taken food 
shortly before the administration of the anaesthetic. They 
may Jast for only a short time, or may persist for hours. 
If persistent, the swallowing of a few mouthfuls of hot 
water will often relieve the condition ; or the administra- 
tion of cocaine hydrochlorate, grain one-quarter, with 
crushed ice, repeated two or three times, or the use of 
crushed ice with champagne or brandy, may be followed 
by satisfactory results. Inhalation of the fumes of vine- 
gar will often prevent nausea and vomiting, the vine- 
gar being poured upon a towel or a piece of gauze, which 
is held over the mouth and nose of the patient, and it 
should be applied as soon as the administration of the ether 
is stopped ; it should be used continuously for some time 
to be followed by the best results. 

Administration of Ether by the Rectum. — A few years 
ago prompt anaesthesia was induced by the administration 
of the vapor of ether by the rectum ; a can of ether 
was placed in warm water to which a tube and nozzle were 
attached. The nozzle was introduced into the rectum. 
This method was abandoned by reason of the irritation of 
the bowel resulting in hemorrhage, which frequently oc- 
curred. Recently the method has been revived in Boston, 
with the modification that the ether is not warmed and the 
vapor is driven into the rectum by forcing air through the 
ether. Satisfactory results as to the prompt production of 
anaesthesia, and non-irritation of the rectum, have been re- 
corded in a number of cases. This method has been used 
in so limited a number of cases that its value cannot yet be 
estimated. 

Ether and Nitrous Oxide Gas.— The production of 
anaesthesia by the combined use of nitrous oxide gas and 
ether has been quite extensively employed both in Eng- 
land and this country. Hewitt considers this method of 



ANAESTHETICS. 199 

producing anaesthesia far superior to any other method 
which we possess at the present time. A special apparatus 
is required, which controls definitely the amount of nitrous 
oxide, ether, and air. Anaesthesia is produced first by the 
use of nitrous oxide gas, and, as soon as this is developed, 
the anaesthetic state is maintained by substituting the vapor 
of ether for the nitrous oxide gas. No air is given with 
the gas until anaesthesia is complete, which should be in 
from two to three minutes. Breathing at this time is 
stertorous, and cyanosis is well marked. After this time 
air is administered with the ether vapor. Anaesthesia by 
this method is rapidly induced, there is less struggling and 
spasm, the quantity of ether employed is smaller, and 
the after-effects are less marked, especially vomiting, and 
recovery from the anaesthetic state is more rapid than 
when ether is used alone. 

Ether and Oxygen. — The administration of ether with 
oxygen gas has been employed to a considerable extent. 
In the employment of this combination to produce amestlie- 
sia the patient is first allowed to inhale a small amount of 
ether from an inhaler, and a tube connected with the 
oxygen receiver is then introduced into the inhaler and 
the oxygen gas turned on, so that the patient is allowed 
at the same time to inhale the vapor of ether and oxygen 
gas. A special apparatus may also be employed which 
regulates definitely the amount of ether and oxygen fur- 
nished. Anaesthesia produced by this combination is 
accompanied by less cyanosis, vomiting is rare, and the 
patient recovers very promptly from the anaesthetic state. 
As the ether vapor and oxygen form a highly explosive 
mixture, care should be exercised not to bring a flame near 
the patient during its administration. 

Chloroform. — This drug according to Hare, first affects 
the brain, then the sensory part of the spinal cord, then 
the motor area of the cord, then the sensory paths of the 
medulla oblongata, and finally the motor portions of the 
medulla, and produces death from failure of the vasomotor 
centre and of the respiratory centre unless, as rarely 
occurs, the heart has succumbed to the drug. 



200 MINOR SURGERY. 

Chloroform is certainly a much more dangerous anaes- 
thetic than ether, and although it is widely used in the 
British Islands and upon the Continent, it is not exten- 
sively used in this country except in certain districts — as 
in the southern and southwestern districts of the United 
States, and here its use is followed by fewer fatalities than 
in the northern districts, so that it is possible that its use 
is safer in warm climates. Clinical experience has demon- 
strated that chloroform may be used in aged and very 
young subjects and in puerperal patients with compara- 
tive safety ; deaths from chloroform are more common in 
the middle period of life. It is also to be preferred to 
ether in patients suffering from emphysema of the lungs, 
bronchitis, and vascular degeneration of the kidneys. It 
is also employed by some surgeons instead of ether in 
operations upon the mouth when the actual cautery is 
used, on account of its less inflammable character. 

Considerable diversity of opinion exists among different 
observers as to whether death resulting from chloroform 
is due to failure of the heart or failure of the respiration, 
and each has brought forward a large amount of evidence 
to prove his views correct. Although it has been demon- 
strated that chloroform is a direct depressant and para- 
lyzant to the heart-muscle or its contained ganglia, and 
that cardiac dilatation of varying degrees may be brought 
about by the administration of chloroform, yet clinical 
experience shows that paralysis of the respiratory centres 
is probably the most important factor in causing death 
during chloroform anaesthesia, for circulatory failure in 
these cases is due to embarrassed or suspended breathing, 
and the only method of treatment which has been found 
of value is that which tends to bring about respiratory 
action, namely, some one of the various forms of artificial 
respiration. 

Chloroform is more dangerous in the earlier stages of 
the administration, and the gravity of the operation ap- 
pears to have little effect in increasing its danger, as sta- 
tistics show that the greatest number of fatalities have 
occurred in minor surgical procedures, such as extracting 



ANESTHETICS. 



201 



teeth, amputation of fingers, reduction of dislocations, and 
opening abscesses. 

Preparation of Patient. — A patient is prepared for the 
administration of chloroform as in the case of ether, the 
same precautions being taken as regards the removal of 
false teeth or foreign bodies from the mouth, and to see 
that the* clothing about the chest and neck does not re- 
strict the circulation or respiratory movements. 

Administration of Chloroform. — Chloroform is adminis- 
tered by pouring a drachm of the drug upon a folded 
towel, which is first held a few inches from the mouth 
and nose, and gradually brought nearer, but is not allow r ed 
to come in contact with the face, as from its local irritat- 
ing action it will blister the surface ; the lips and anterior 
nares should be anointed with vaseline. 

The ansesthetizer should remember that one of the dan- 
gers in the administration of chloroform is the risk of too 
great concentration of its vapor, so that 
he should see that a sufficient admixt- Fig. 160. 

ure of atmospheric air takes place. 

Chloroform may also be administered 
with Esmarch's inhaler, which consists 
of a wire frame covered with gauze 
(Fig. 160). 

A arious inhalers have been devised 
to regulate the amount of chloroform 
administered and to secure the proper 
admixture of atmospheric air, and the 
best of these is probably Mr. Clover's 
apparatus. 

Profound chloroform anaesthesia is 
manifested by insensibility of the con- 
junctiva to the touch, absence of the 
reflexes, complete muscular relaxation, 
and, usually, contracted pupils. When Esmarchs inhaler. 
this stage is reached, the inhalation 
should be stopped, and after this time only so much chlo- 
roform should be administered as is sufficient to keep the 
patient fully under its influence. 




202 MINOR SURGERY. 

Complete anaesthesia should be produced before any 
operation is begun ; if undertaken before that time, syn- 
cope may be produced by reflex inhibition of the heart. 
If convulsive movements take place before the patient is 
fully anaesthetized, and the face becomes cyanosed, the 
inhalation should be discontinued until these symptoms 
disappear. The pupils should also be watched careful lv, 
to see if they respond to light or are contracted. If 
the anaesthesia is not complete, insensibility to light or 
wide dilatation is a sign of danger which calls for re- 
moval of the anaesthetic and active treatment to stimu- 
late the circulation and respiration. If the inhalation 
has been stopped and is again in a short time resorted to, 
it should be given very carefully and slowly, for syncope 
may suddenly develop from the fact that the heart or the 
respiration may feel the eifect of the previous use of the 
drug. 

Accidents during Chloroform Anaesthesia. — Mechanical 
asphyxia may occur during anaesthesia produced by chloro- 
form, as well as that by ether, by obstruction of the res- 
piratory passages by blood, mucus, foreign bodies, or the 
tongue falling backward over the epiglottis. These acci- 
dents should be treated in the same manner as when 
occurring during etherization. 

Death during the administration of chloroform may 
result from cardiac syncope or from respiratory arrest, 
and the dangerous symptoms develop so rapidly that the 
greatest promptness is required to meet them. The per- 
son administering chloroform should constantly watch 
both the pulse and the respiration, and should not for a 
moment have his attention diverted from the patient ; 
great vigilance is here, if possible, more important than 
during the administration of ether. 

Respiratory Arrest — During chloroform anaesthesia 
paralysis of the respiratory centres may occur, giving rise 
to respiratory arrest. If this dangerous symptom appears, 
the patient's head should be lowered and artificial respi- 
ration promptly employed to re-establish the respiratory 
function. 



ANESTHETICS. 203 

Cardiac syncope developing during the administration 
of chloroform, manifested by pallor, fluttering or arrested 
pulse, and ees-ation of respiration, should be treated by 
lowering the patient's head or inverting the patient, the 
use of a rapidly interrupted electric current, the hypo- 
dermic injection of digitalis, atropine, or strychnine, and 
the employment of artificial respiration, either Silvester's, 
the direct method, or Laborde's method ; and, as in cases 
of threatened death from ether, the treatment should not be 
desisted from for some time, as by persistent employment of 
these means apparently hopeless cases have been resuscitated. 

Chloroform and Oxygen. — The combined use of chloro- 
form and oxygen is sometimes employed to produce anaes- 
thesia. A small amount of chloroform is first adminis- 
tered, and then the oxygen gas is introduced into the 
inhaler, and the two gases are inhaled at the same time ; 
or a special apparatus may be employed, by means of 
which a definite amount of each drug may be administered. 

Chloroform and Ether. — The induction of anaesthesia 
by the administration of ether followed by chloroform, as 
recommended by Hewitt, has beeu practised in a large 
number of cases with satisfactory results. In producing 
anaesthesia by this method, ether is first given until anaes- 
thesia is produced, and the anaesthetic effect is then kept 
up by the administration of chloroform. Hewitt considers 
it advisable in this method of anaesthesia to let the patient 
come up slightly, so that there is conjunctival reflex, before 
the chloroform is substituted, and also advises that the 
operation should not be undertaken until that change has 
been made. 

_ The A.-C.-E. Mixture.— This mixture, which con- 
sists of 3 parts of chloroform, 1 part of ether, and 1 part 
of alcohol, has been employed by some surgeons in place 
of ether or chloroform, with the idea that the dangers 
of chloroform are diminished by its combination with 
ether and alcohol. Clinical experience, however, has not 
proved this view to be correct. If administered with as 
much care as chloroform, its administration is accompanied 
with the same safety. It should be administered upon a 



204 MINOR SURGERY. 

towel or inhaler in the same manner as chloroform, and 
the patient should be watched as carefully daring its inha- 
lation as daring the administration of the latter drag, and 
any complications occurring shonld be treated in the same 
manner as those arising during the nse of chloroform. 

Schleich's Anaesthetic Mixture. — Schleich has re- 
cently introduced an anaesthetic mixture which he con- 
siders safer than ether or chloroform. He maintains that 
the absorption of a general anaesthetic is chiefly regulated 
by the boiling-point or point vi maximum evaporation of 
the anaesthetic. An anaesthetic is unsafe in direct propor- 
tion to the amount absorbed; and the lower the boiling- 
point of the anaesthetic the less is absorbed ; hence an 
anaesthetic to be safe should have a low boiling-point. A 
safe anae-thetic is one in which the point of maximum 
evaporation is near the temperature of the patient, so that 
a- much of the anaesthetic will be exhaled upon expiration 
as is iuhaled on inspiration. Schleich empiovs three 
mixtures. The first contains, by volume, chloroform, siss : 
petroleum ether, sss : sulphuric ether, svj. The second 
contains chloroform, siss : petroleum ether. §ss : sulphuric 
ether. 5 v. The third contain- chloroform, §j ; petroleum 
ether, sss ; sulphuric ether, jfij ."iis-. This anaesthetic may 
be administered upon a towel or inhaler. It is claimed 
that by the use of these anaesthetic mixtures little excite- 
ment is produced and cyanosis rarely occurs ; that there i- 
no hypersecretion of mucus and no consecutive bronchitis 
or pneumonia, and that the anaesthetic state is quiet, reaction 
is rapid, and vomiting occurs in less than half the cases. 

Bromide of Ethyl. — This drug was introduced as an 
anaesthetic some year- ago, but as a number of deaths fol- 
lowed its use, it was abandoned. The time required to 
luce anaesrhesia is shorter than for ether, but the: 
n induced violent muscular spasm, which renders it an 
unsuitable anaesthetic in many ca— -. 

Bromide of ethyl has again been revived as an anaes- 
thetic, but clinical experience has proved that its use is 
not devoid of danger, that it is not as safe as ether, and 
that it l — ss s no advantage- in point of safety over 



ANESTHETICS. 205 

chloroform. When used, it should be administered by 
pouring a drachm or two upon an inhaler or a towel, and 
the patient should be watched with the same care as dur- 
ing- the administration of chloroform. 

Chloride of Ethyl or Kelene. — This drug has re- 
cently been employed by inhalation to produce general 
anaesthesia. It is principally used to produce anaes- 
thesia for short operations, or may be used to bring 
about anaesthesia, which is afterwards continued by the 
use of ether. The advantages of its use are that anaesthe- 
sia can be produced in a few minutes and that recovery 
is rapid and unaccompanied by nausea or other unpleasant 
symptoms. 

It is administered in the same manner as ether, the spray 
being directed into a cone or inhaler. 

Scopolamine. — During the last five years scopolamine, an 
alkaloid closely resembling hyoscine, has been used as an 
adjuvant to general anaesthesia. It is usually employed in 
combination with morphine, either in repeated doses with- 
out anv other anaesthetic, or in a single dose preliminary t<> 
inhalation anaesthesia, ether or chloroform being employed. 
In the former method, the usual procedure is to give three 
hypodermic injections of scopolamine hydrobromate, gr. 
yi^ (0.0004 gramme), and morphine sulphate, gr. \ (0.008 
gramme), at intervals of a half-hour to an hour before 
the operation. The solution of scopolamine should be 
freshly made, as it decomposes rapidly if kept for more 
than a few days. If the drug acts well, the patient 
becomes sleepy* after the first injection, is fast asleep after 
the second, and unconscious and insensible to pain after 
the third. The third injection is not usually felt by the 
patient. After the operation is finished the patient is 
returned to bed unconscious, and continues to sleep for 
five hours after the last injection. In the latter method, a 
hvpodermic injection of scopolamine hydrobromate, gr. -^ 
(6.00065 gramme), and morphine sulphate, gr. l-l (0.01- 
0.016 gramme), is given about half an hour before general 
anaesthesia is begun. The advocates of each method re- 
port very favorable results. It is probable that the second 



206 MINOR SURGERY. 

is, on the whole, the safer and more satisfactory. It cer- 
tainly reduces the amount of ether or other anaesthetic 
employed, and almost entirely abolishes the disagreeable 
after-effects. 

Aiter-effects of Anaesthetics. — Nausea is not common 
after chloroform anaesthesia. The treatment of this con- 
dition following etherization has been previously de- 
scribed. The temperature is usually notably lowered by 
anaesthetics, so that it is always well to apply artificial 
heat and keep the patient well covered. A form of 
mental disturbance known as confusional insanity is often 
attributed to the use of anaesthetics, but, as it does not 
usually develop until some time, often two or three weeks, 
after their employment, H. C. Wood is of the opinion 
that the relation between the mental symptoms and the 
anaesthetic has not been clearly proved in these cases, and 
that it is rather the outcome of a peculiar depression of 
the cerebral cortex produced by the shock of the opera- 
tion itself, or by the emotional strain due to the surgical 
illness. This view seems to be confirmed by the fact 
that many of the cases of emotional insanity which are 
observed follow injuries in which no anaesthetic has been 
given. Albuminuria and glycosuria may follow the 
administration of ether or chloroform, but are usually 
only temporary conditions. 

Paralysis of the nerves of the brachial plexus may follow 
prolonged anaesthesia when the arm is drawn high above 
the head ; it is not due to the anaesthetic, but results from 
stretching of the nerves over the head of the humerus or 
their compression between the clavicle and the first rib. 
Paralysis of the musculo-spiral nerve may also occur from 
prolonged pressure of the arm upon the edge of the table. 

Hypnotism. — The anaesthetic state of hypnotism has 
been utilized for the performance of surgical operations. 
Schmeltz and others have recorded operations done under 
this influence, the patient apparently suffering no pain. 
While there is no doubt that the anaesthetic state can be 
obtained by hypnotism, which might be serviceable in 
surgical operations, yet we do not believe that it will be 
of general utility. 



TRUSSES. 207 



TRUSSES. 



A truss for the palliative treatment of hernia is a 
mechanical contrivance with one or more pads and a 
strap : these are held in position by a spring to which 
they are attached, which holds the pad in contact with the 
skin over the hernial opening. 

Trasses are usually applied in cases of reducible and 
sometimes in irreducible hernise, and are used in the treat- 
ment of hernia? at all ages ; in infants and young children 
the continued use of a properly fitting truss is often fol- 
lowed by a radical cure of the hernia. They are made 
with steel or rubber springs and with pads of wood, 
rubber, celluloid, or horsehair, covered with chamois skin; 
their shape and the pressure which they should exert vary 
with the variety of hernia for which they are applied. 

A firm compress applied over the inguinal canal or 
crural ring, secured in position by a firmly applied spica- 
of-the-groin bandage, forms a very satisfactory temporary 
means of preventing the descent of a hernia. 

A properly fitting truss should be worn without dis- 
comfort to the patient — that is, should not make too 
much pressure upon the skin at the points where the pads 
are applied, and should absolutely prevent the descent of 
the hernia. In testing the adequacy of a truss, after 
application, to prevent the escape of the hernia, the 
patient should be instructed to separate his legs, bend for- 
ward over the back of a chair, and cough or strain forcibly; 
if this does not bring the hernia down, control of the rupt- 
ure may be considered satisfactory. 

Trusses should be applied after the complete reduction 
of the hernia, while the patient is in the recumbent pos- 
ture. When first applied, the truss should be worn both 
during the night and day ; and if the skin becomes tender 
at the points of pressure, it should be sponged with 
alcohol and alum, then dried and dusted with powdered 
starch or lycopodium. Patients at first sometimes com- 
plain of discomfort in wearing a truss, but they soon 
become accustomed to its presence. After a truss has been 



208 



MINOR SURGERY. 



Fig. 161. 



worn for some time, its use at night, while the patient is 
in bed, may be dispensed with, but the patient should not 
remove it until he is in bed in the recumbent posture, and 

he should reapply it before he 
rises in the morning. In chil- 
dren it is better to have the 
truss worn continuously ; and 
if it is removed for bathing, 
the nurse should be instructed 
to place her finger over the 
ring to prevent descent of the 
hernia until the truss is ap- 
plied. In applying trusses to 
male children care should be 
taken not to make pressure 
upon an undescended testicle. 
Worsted Truss. — This ap- 
pliance may be used in the 
treatment of inguinal hernia 
in infants, and is made from 
an ordinary skein of worsted, 
one part of which is made to 
pass around the body just 
above the iliac crests, the other joins this in front and 
behind, forming a perineal band. The knot made by the 
two bands in front should be directly over the inguinal 
ring (Fig. 161). 

Trusses for Inguinal Hernia. — In measuring a patient 
for this form of truss, the circumference of the body mid- 
way between the crest of the ilium and the great trochan- 
ter should be taken, and the distance from the symphysis 
pubis to the anterior superior spinous process of the ilium 
may also be given, as half of this distance corresponds to 
the position of the internal abdominal ring. In reducible 
inguinal hernia the truss-pressure should be exerted upon 
the inguinal canal and directly backward. To control this 
variety of hernia, a single-spring truss (Fig. 162) may be 
employed, or the use of a truss having a double spring 
with flat pads on each side of the spine attached to the 




Worsted truss. i^Beewek.) 



TR USSES. 



209 



springs, and a smaller pad over the inguinal canal on the 
unaffected side, with a full pad on the side of the hernia, 
will often be efficient. This, which is known as Hood's 
truss, is one which will be found a very satisfactory in- 
strument, both in inguinal and femoral hernia (Fig. 163). 



Fig. 162. 



Fig. 163. 




Truss for inguinal hernia. 



Hood's truss. 



Trusses for Femoral Hernia.— In measuring a patient 
for this variety of truss, the circumference of the body 
midway between the crest of the ilium and the great tro- 
chanter should be taken ; the distance of the saphenous 
opening from the symphysis pubis, as well as from the 
anterior iliac spine, should also be taken. In reducible 



Fig. 164. 



Fig. 165. 




Hood's truss for femoral hernia. 



Truss for umbilical hernia. 



femoral hernia the truss-pressure should be directed back- 
ward against the femoral canal, and the pad should be 
large enough to make pressure upon the adjacent tissues 
through which the hernia passes, as well as upon the re- 
laxed tissues covering the femoral canal. As in inguinal 
hernia, either a single or a double spring truss may be em- 
ployed (Fig. 164). 

In applying a truss for femoral hernia, care should be 
taken to see that the pad does not rest upon the pubis, 

14 



210 MINOR SURGERY. 

and thus remove the pressure from the crural ring and adja- 
cent tissues and prevent the proper control of the hernia. 

Trusses for Umbilical Hernia. — In measuring a patient 
for this variety of truss, the circumference of the body- 
over the umbilicus should be taken. In reducible um- 
bilical hernia the truss-pressure should be directed back- 
ward, and the pad should bear rather on the tendinous 
margins of the ring than on the hernial opening. A 
truss for this variety of hernia should have a flat or 
slightly convex pad, which is held in position over the 
umbilical ring by means of springs having counter-pads 
on either side of the spine attached to their extremities ; 
these are fastened together by a strap (Fig. 165). 

A simple and satisfactory truss for umbilical hernia in 
infants consists of a penny covered by adhesive plaster, or 
a small flat compress of linen, held over the umbilical ring 
by one or two strips of adhesive or rubber plaster about 
two inches in width, or by a broad strip of perforated 
rubber adhesive plaster, which should be applied so as to 
cover in about the anterior two-thirds of the circumfer- 
ence of the body. A penny, or a small flat compress 
of linen, will be found much more satisfactory than the 
conical rubber or cork pad often recommended. 

Trusses for Irreducible Hernia.— The application of 
a truss to this variety of hernia protects it from injury 
and prevents its further protrusion. Such trusses are 
secured in the same way as those for reducible hernia, 
but the pads are made concave or cup-shaped, or may 
have an air-cushion or water-cushion attached to the pad. 



CATHETERS AND BOUGIES. 

Catheters are hollow tubes, made either of metal, India- 
rubber, or other flexible substances. 

Sterilization of Catheters and Bougies. — To avoid 
infection of the urethra and bladder, it is important that 
catheters and bougies should be sterilized thoroughly before 
being introduced (see page 326), 



CATHETERS AST) BOUGIES. 211 

Infection of the bladder may occur from matter con- 
tained in the urethra, so that this canal should also be 
sterilized (see page 326). If it is possible, the patient should 
pass the urine to wash out the urethra, and a solution of 
boric acid or a borosalicvlic solution should be injected 
before the instrument is passed. 

To lubricate the instrument, sterilized boroglyceride, 
olive oil, glycerin, or lubrichondrin should be employed. 

Metallic Catheters. — These are made of silver, or. if 
constructed of other metals, they should be plated with 
silver or nickel, to give them a smooth, bright surface 
which can easily be kept perfectly clean ; and their shape 
should conform to that of the normal urethra (Fig. 166). 
The shape of the metallic catheter is sometimes changed 
to meet certain indications : for instance, for use in cases 
of enlarged prostate it is longer and has a larger curve 
than the ordinary instrument (Fig. 167). The metallic 
female catheter is shorter and has a much -mailer curve 
than the instrument used for the male urethra. A female 
catheter made of glass is now frequently emploved, and 
has the advantage of easy sterilization. 

Flexible Catheters. — The most commonly used variety 
of flexible catheter is that known as the English cathe- 
ter, which is made of linen and shellac, and is provided 
with a stylet ; it can be moulded into any shape desired 
by dipping it into hot water, which renders it flexible, 
and, after moulding it to the proper curve, this can be 
fixed bv immersing it in cold water, which hardens it 
again. 

The French flexible catheter is made of India-rubber, 
or a combination of this material with other substances. 
These instruments are conical toward their extremities, 
and terminate in an olive-shaped point ; they are pro- 
vided with one or two smoothly finished eyes near the 
vesical extremity (Fig. 168). 

Another form of flexible catheter, known as the el- 
bowed catheter, or Mercier's catheter (Fig. 169), has an 
angle or elbow near its vesical extremity ; this is often 
found a satisfactory instrument to use in cases of enlarged 



212 



MINOR SURGERY. 



prostate. A variety of flexible catheter made of soft India- 
rubber is also sometimes employed (Fig. 170). 

Catheters and bougies are made according to a certain 



Fig. 166. 



Fig. 167. 



Fig. 168. 



Fig. 169. 




Metallic catheter. 



Prostatic catheter. French flexible Mercier's 

catheters. elbowed 

catheter. 



scale. The English scale runs from No.'l to No. 12; 
the American, from No. 1 to No. 20 ; and the French, 
from No. 1 to No. 40. 




INTRODUCTION OF A CATHETER. 213 

Bougies and Sounds. — Bougies. — These are flexible 
instruments which correspond in size and shape to the 
English and French catheters ; and besides there are the 
acorn-pointed bougie (Fig. 171) and the filiform bougie, 
which latter is made of whalebone or of the same material 
as the ordinary French bougie and catheter. These in- 
struments are of very small 
diameter, and may often be j2°- • 

passed through strictures 
which will admit no other form 
of instrument (Fig. 172). 

Sounds. — These are solid in- 
struments, usually of steel, 
with a smooth surface and 
plated with nickel ; they corre- 
spond in size and have the 
same curve as the metallic 

catheter; the handle is flattened, to allow the operator to 
'grasp them firmly; they are employed in the treatment of 
strictures by dilatation (Fig. 173). The sound used in 
dilating strictures of the meatus is straight, and is shorter 
than the sound employed in the treatment of urethral 
strictures (Fig. 174). A metallic sound with a shorter 
curve than the ordinary sound is used for exploration of 
the bladder for calculus or tumor. 

Introduction of a Catheter. — For the introduction of 
a catheter, the patient may be in the standing, sitting, or 
recumbent posture — the latter is the best in most cases ; 
he should rest squarely on his back, and have the thighs 
a little flexed and separated. 

Before passing a metallic catheter, the surgeon should see 
that it has been sterilized, and after warming and oiling it 
he stands upon the left side of the patient and grasps the 
penis with the left hand, and turns it over the pubis and 
introduces the beak of the catheter into the meatus, and 
gently passes it along the urethra until its point passes 
beneath the symphysis pubis ; at this point the handle is 
elevated and gently depressed between the thighs, when 
the beak will pass into the bladder (Fig. 175). 



214 



MINOR SURGERY. 



In passing a catheter in case of enlarged prostate, when 
the prostatic region is reached difficulty is sometimes ex- 
perienced in the further passage of the instrument ; this 



Fig. 171. 



Fig. 172. 



Fig. 173. 



Fig. 174. 







(/ 







Bulbous or acorn- 
pointed bougies. 



Filiform 
bougies. 



Steel sound. 



Sound for dilating 
meatus. 



may be overcome by introducing the finger into the rectum 
and guiding the catheter through the prostatic urethra ; or 
if the prostate is found much enlarged, the catheter should 
be withdrawn, and a prostatic catheter (Fig. 167) substi- 






INTRODUCTION OF A CATHETER. 215 

tuted. The same manipulation is practised in passing 
metallic sounds. 

Flexible catheters and bougies are passed by grasping 
the penis and holding it in such a position that it is at 
a right angle to the axis of the body, and the catheter 
or bougie is introduced into the meatus and conducted 

Fig. 175. 




Introduction of a catheter. (Vollleaiier. 



through the urethra into the bladder by gently pushing 
the instrument downward. In this variety of instrument, 
which has no curve, the surgeon has no means of guiding 
the point of the instrument, and if an obstruction is met, he 
should withdraw the instrument slightly and make another 
attempt ; all manipulations should be extremely gentle. 



216 MINOR SURGERY. 

Passing the Female Catheter. — It was formerly con- 
sidered important to pass the female catheter without 
exposing the patient. At the present time it is rarely 
done, as it is considered more important to sterilize the 
vulva and region of the orifice of the urethra to avoid 
infection of the bladder. After washing the vulva with 
soap and water, and irrigating it with boric solution or 
normal salt solution, the orifice of the urethra is exposed, 
by separating the nymphse, and the catheter is introduced 
into the bladder. 

Catheterization of the Ureters in the Female. — In 
performing this operation by the direct or Kelly's method, 
the patient is placed in the dorsal position with the pelvis 
elevated or in the genu-pectoral position, and the urethra is 
dilated to admit a cylindrical speculum 12 to 15 millimetres 
in diameter. With the aid of a head-mirror the interior 
of the bladder can be directly inspected. The opening of 
the ureter may be exposed by turning the speculum thirty 
degrees to one side, and is recognized as a small depres- 
sion, the mucous membrane being of a darker color than 
elsewhere. A delicate elastic or silver catheter can be 
introduced into this opening, and by careful manipulation 
may be passed to the pelvis of the kidney. By this pro- 
cedure, unilateral or bilateral disease of the kidneys may 
be clearly demonstrated, as well as the condition of the 
ureters themselves. Delicate bougies passed into the 
ureters may be used to locate their position in the opera- 
tion of hysterectomy. Catheterization of the male ureters 
can also be practised. 

Segregation of the Urine. — To obtain the urine es- 
caping from each ureter, so that the condition of each kid- 
ney may be ascertained, an instrument devised by Harris, 
of Chicago, may be employed. The device is known as a 
segregator. 

Tying the Male Catheter in the Bladder. — When it 
is desirable to retain a catheter for some time in the male 
bladder, it is necessary to secure it, to prevent its slipping 
out. Either a metallic or flexible catheter may be em- 
ployed ; but, as a rule, the flexible instrument is the most 



SECURING CATHETER IN BLADDER. 217 

comfortable to the patient, and is to be preferred ; there 
are several methods of securing it in the bladder. 

By one method, two narrow strips of tape or two or three 
strong silk ligatures are attached to the rings at the end of 
a metallic catheter, or are securely fastened around the end 
of the flexible instrument ; these are next brought back- 
ward, one on each side of the penis, and the skin is drawn 
forward and a strip of adhesive plaster half an inch in 
width is passed over the strings or tapes and carried three 
or four times around the body of the penis just behind the 
glans. If the skin has been brought well forward before 
the strips have been applied, the ligatures are tightened 
as it slips back, and the cathe- 
ter has not too much play Fro- i" 6 - 
(Fig. 176). 

Another method consists in 
fastening a strong silk ligature 
around the catheter just in ad- 
vance of the meatus ; the two 
ends are next brought back- 
ward and tied in a knot behind 
the corona glandis ; the ends Tying in catheter. (Bbyaut. 
are then carried around the 

penis behind the corona and tied on one side of the frcenum ; 
the foreskin is slipped forward and covers the ligatures. 

A catheter may also be secured in the bladder by tying 
the ends of the silk ligatures, which are attached* to the 
instrument in advance of the meatus, to tufts of pubic hair. 

Another method of securing the catheter is to perforate 
the free end with a needle armed with a double ligature 
of silk or hemp ; the needle being removed, two loops are 
made of the proper length, and these are passed through 
the ends of a T-bandage, which is secured around the waist, 
the tails being brought up on either side of the scrotum and 
secured to the body of the bandage passing around the waist. 

In the female, when it is desirable to keep the bladder 
empty, the self-retaining catheter is usually employed, 
which consists of a catheter with a bulb at its vesical 
extremity, or an ordinary catheter with silk loops, and a 




218 



MINOR SURGERY. 



Fig. 177. 




T-bandage may be employed in the same manner as in 
securing a male catheter. 

Irrigation of the Bladder. — This procedure may be 
required in the treatment of cystitis or iu sterilizing the 
bladder, and is accomplished by passing a flexible cath- 
eter with a large eye into the bladder, or 
a double or two-way catheter may be em- 
ployed. A syringe, or, better, a rubber 
bulb holding about a pint, having a noz- 
zle and stopcock (Fig. 177), is filled with 
warm water, or with any medicated solu- 
tion which is desired, and it is then at- 
tached to the free end of the catheter and 
the contents are gently injected into the 
bladder ; care should be taken that the 
bladder is not too much distended. When 
the desired amount of fluid has been in- 
jected, it is allowed to run out of the cath- 
eter, and the procedure may be repeated 
until the solution comes away perfectly 
clear. 

The bladder may also be irrigated with- 
out using a catheter, the resistance of the compressor mus- 
cle of the urethra being overcome by the pressure of a col- 
umn of water. The patient sits in a chair and a rubber or 
glass nozzle with a large bulbous tip, which closely fits the 
meatus, is inserted into it ; the nozzle is connected by a rubber 
tube with a reservoir containing the fluid for irrigation. The 
reservoir is raised to a height of three to six feet above the 
patient. He is directed to take deep inspirations, and soon 
the bladder becomes filled with water, when the nozzle is 
removed, and the patient empties the bladder naturally. 
In some cases a little time is required before the column 
of water overcomes the resistance of the compressor muscle, 
or its entrance into the bladder may be hastened by direct- 
ing the patient to attempt to urinate. 

Care should be taken to see that the bladder is perfectly 
emptied of the solution, and in cases of paralysis of the 
viscus gentle pressure should be made upon the abdoinen 



Rubber bag with 
stopcock, for irriga- 
tion of the bladder. 



URETHRAL INJECTIONS. 



219 



over the pubis to accomplish this object. Solutions of 
boric acid and permanganate of potassium, and weak solu- 
tions of carbolic acid and of nitrate of silver or argyrol 
are often employed in washing out the bladder in cystitis. 
Urethral Injections. — In the treatment of urethral 
inflammations, the injection of medicated solutions is gen- 
erally made use of ; and as these injections 
are usually made by the patient himself, he 
should be shown or instructed how to em- 
ploy them. A rubber syringe having a 
conical nozzle, and holding about two or 
three drachms, is the best instrument to 
employ for this purpose (Fig. 178). The 
syringe having been filled with the solution, 
the patient sits upon the edge of a hard 
chair, with the thighs separated, grasps the 
syringe between the thumb and middle 
finger of the right hand, the tip of the 
index finger resting upon the end of the 
piston, and inserts its conical end from a 
quarter to half an inch within the meatus, 
which is held open by the thumb and finger shape of nozzle of 

n . 1/^iT 4/i i • i • urethral syringe. 

ot the lett hand. Alter the introduction 
of the nozzle of the syringe the tissues should be pressed 
tightly around it, the pressure being made laterally, so as 
to narrow the urethral opening instead of broadening it, 
as is the case when compression is made in an antero-pos- 
terior direction. After the fluid has been thrown into the 
urethra in this manner, the syringe is removed, and the 
patient is instructed to hold the lips of the meatus together 
for one or two minutes, to prevent escape of the fluid. 

Urethral irrigation may also be practised by means of 
gravity, a short rubber or glass tube, or a glass urethral 
nozzle being connected by a rubber tube with a reservoir 
containing the fluid to be used, the reservoir being placed 
slightly above the patient. 




220 MINOR SURGERY. 



SUTURES. 

A variety of materials are employed for sutures, sucb 
as silk, catgut, silver or iron wire, silkworm-gut, kan- 
garoo-tail tendon, and horsehair. The materials most fre- 
quently employed at the present time are either catgut, 
silk, or silk worm -gut, although some surgeons prefer 
silver wire. Catgut and kangaroo-tail tendon are practi- 
cally the only substances employed which are absorbable ; 
the other varieties of suture require removal after their 
application, although some sutures, such as the silk, if 
absolutely sterile, when buried in wounds may be cut 
short, as they are apt to become encysted and remain in- 
definitely in the tissues. It matters little what variety 
of material be employed for suturing if the surgeon is 
careful to see that it is rendered thoroughly aseptic before 
being brought in contact with the wound. 

Sutures of Relaxation. — These sutures are entered and 
brought out at some distance from the edges of the wound, 
and are employed to prevent dangerous tension upon the 
sutures which approximate the edges of the skin. This 
form of suture is employed in the quitted, button, or plate 
suture. 

Sutures of Coaptation. — These are superficial sutures 
applied closely together, and include only the skin ; they 
are employed to secure accurate apposition of the cuta- 
neous surface of wounds. 

Sutures of Approximation. — These sutures are applied 
deeply into the tissue to secure approximation of the deep 
portions of a wound ; this object is accomplished by the 
use of the quilled, buried, button, or plate suture. 

Secondary Sutures. — These sutures are applied when the 
surfaces of the wounds are covered by granulations, when 
the primary sutures have failed to secure apposition of the 
edges of the wound, in cases of secondary hemorrhage 
where the opening of the wound has been necessitated to 
turn out the blood-clot and secure the bleeding vessel, and 
in plastic operations where the primary sutures have failed 
to secure adhesions of the edges of the flaps. They are 









SUTURES. 221 

also employed with advantage in closing wounds in eases 
in which it was necessary to pack the wound with anti- 
septic gauze, or to allow haemostatic forceps to remain 
clamped upon bleeding tissues in the wound at the time of 
operation. The sutures should in such a case be intro- 
duced and loosely tied at this time, and when the packing 
or forceps is removed at the end of two or three days the 
sutures are tightened so as to secure apposition of the 
edges of the wound. 

Surgical Needles. — Xeedles for surgical use are of 
different sizes and shapes i Fig. 179); straight needles are 

Fig. 179. 




Surgical needles. 

the ones commonly employed, but curved needles will be 
found most convenient for the introduction of sutures 
in wounds in certain locations. Hasredorn needles, which 
are flat and have sharp-cutting edges, make a narrow 
linear wound in the tissues, and are useful in some 
cases. For the introduction of sutures in the intestines 
or hollow viscera, the ordinary sewing-needle is generally 
employed, as it does not cut the ti— ties, but merely sepa- 
rates them, and its puncture is not likely to bleed. Tubu- 
lar needles are often employed in introducing sutures in 
wounds in which the use ol an ordinary needle is diffi- 
cult : for instance, in the operation for cleft palate, and for 
the introduction of sutures in deep wounds, a mounted 
needle will often be found very useful (Fig. 180). Eev- 
erdin's needle, which consists of a handled needle with an 



222 



MINOR SURGERY. 



eye which is closed with a slide, is useful in passing deep 
sutures. The needle is first passed through the tissues, 
then threaded and withdrawn, carrying the suture with 
it. Needles should be sharp and clean, and should be 
rendered thoroughly aseptic before being used. Needles 
should be sterilized by boiling, and may be preserved in a 
saturated solution of carbonate of sodium or albolene to 
prevent rusting. A needle-holder is often required for 

Fig. 180. 




Mounted needle. 



the satisfactory introduction of sutures in wounds in 
certain localities (Fig. 181); if this is not at hand, the 
needle may be held by a pair of dressing-forceps or a 
pair of haemostatic forceps. 



Fig. 181. 




Needle-holder. 



Method of Securing Sutures and Ligatures.— 

Metallic sutures are usually secured by twisting the ends 
together or by passing the ends through a perforated shot 
and clamping the shot with a shot-compressor, which 
securely fixes them. 

Sutures and ligatures of catgut, silk, silkworm-gut, 
kangaroo-tail tendon, or horsehair are secured by tying, 
and several different knots are employed to secure them. 



SUTURES. 



223 



Fig. 182. 



Reef or Flat Knot. — This is one of the best forms of 
knot to use in securing sutures or ligatures, and it is 
made by passing one end of the thread over and around 
the other end, and the knot 
thus formed tightened ; the 
ends of the thread are next 
carried toward each other and 
the same end is again carried 
over and around the other, 
and when the loop is drawn 
tight we have formed the reef 
or flat knot (Fig. 182). 

Surgeon's Knot. — This knot 
is formed by carrying one end 
of the thread twice around the other end (Fig. 183) ; and 
after tightening this loop the same is carried over and 

Fig. 183. 




Reef or flat knot. 




Surgeon's knot. 

around the other end as in the case of the final knot of 
the reef or flat knot. The surgeon's knot and reef knot 
combined is one of the best methods of securing sutures 
or ligatures of catgut or silk, as the first knot is not apt 
to relax before the second knot is applied (Fig. 184). 

Granny Knot. — This method of tying the ligature or 
suture should not be employed, as the resulting knot is 
not as secure as the reef knot and is apt to relax : it differs 
from the latter in the fact that one end of the thread hav- 
ing been carried across and around the other end, the knot 
is completed by carrying the same end under and around 
the other end of the thread (Fig. 185). 

Staffordshire Knot. — This is much used to secure the 
pedicle in the removal of abdominal tumors, and is applied 



224 



MINOR SURGERY. 



as follows : A handled needle armed with a stout silk liga- 
ture is passed through the pedicle, and then withdrawn so 
as to leave a loop on the distal side ; this loop is drawn 
over the tumor, and one of the free ends is passed through 
it so that one end is above while the other end is below the 
retracted loop (Fig. 186). The ends are then seized and 

Fig. 184 




Surgeon's knot and reef knot combined. 



drawn through the pedicle ; at the same time the thumb 
and forefinger are pressed against it until sufficient con- 
striction is made, and the ends are finally secured by tying 
as in the securing of an ordinary ligature. 



Fig. 185. 



Fig. 186. 





Granny knot. Staffordshire knot. 

Varieties of Sutures. 

The Interrupted Suture. — This variety of suture, 
which is the one most usually employed in the apposi- 
tion of wounds, consists of a number of single stitches, 
each of which is entirely independent of those on either 
side. In applying this suture, the surgeon holds the edge 



SUTURES. 



225 



Fig. 187. 




Interrupted su- 
ture. (Park.) 



of the wound with the fingers or forceps and thrusts the 
needle, previously threaded, through the skin three or four 
lines from the edge of the wound. He 
then passes the needle from within outward 
through the tissues of the opposite flap at 
the same distance from the edge of the 
wound (Fig. 187). Each stitch is secured 
as soon as it is passed — by tying if a silk, 
catgut, or silkworm-gut suture be used, or 
by twisting if a silver wire suture is em- 
ployed. 

A suture may be used with a needle 
threaded on each end, in which case both 
needles are passed from within outward. 
The sutures may be secured as soon as ap- 
plied, or they may be left unsecured until 
a sufficient number have been introduced, 
and then they may be secured by tying or 
twisting. Care should be taken to sec that 
they make no tension on the edges of the wound, and that 
they are so introduced as to make the best possible apposi- 
tion of the parts. 

Buried Sutures. — In extensive and deep wounds it may 
be found necessary to introduce both deep and superficial 
sutures, the former bringing about apposition of the mus- 
cles and deep fascia, the superficial layer bringing together 
the superficial fascia and skin. 

Deep or buried sutures are often employed to unite 
fascia, muscles, or tendons, and the best material for this 
variety of suture is either catgut, silk, silkworm-gut, or 
kangaroo-tail tendon. 

Continued Suture. — This variety of suture is applied 
in the same manner as the interrupted suture, but the 
stitches are not cut apart and tied ; it is made with silk 
or catgut, and is secured by drawing it double through 
the last stitch and using the free end to make a knot with 
the double portion attached to the needle (Fig. 188). This 
suture may be used in intestinal wounds, but may also be 
employed in obtaining apposition of the edges of wounds 
in tissues of loose strucure. 



15 



226 



MINOR SURGERY. 



Chain-Stitch Suture. — This is a variety of continued 
suture which differs from the ordinary continued suture, 



Fig. 188. 



Fig. 189. 





Continued or glovers' suture. (Park.) Chain-stitch suture. (Brewer.) 

in that the loop is made on one side of the wound as soon 
as the suture has been passed (Fig. 189). 

Fig. 190. 







^^V 






Subcuticular suture. 



Subcuticular Suture. — Halsted has introduced a suture 
in which the needle is introduced on the under surface of 



SUTURES. 227 

the skin on one side, and brought out just beneath the cut 
edge ; it is then entered in the reverse direction below the 
epidermic surface opposite ; when tied, it will lie wholly 
out of sight. The object of this variety of suture is to 
avoid infection of the wound by the skin coccus, which 
may be introduced by the suture if passed from without 
inward. Fine silk or catgut should be used for this variety 
of suture, which may become encysted, absorbed, or grad- 
ually cast off after a few weeks. If employed as a con- 
tinuous suture, the free ends may be tied together, and 
the suture subsequently removed by cutting the loop and 
drawing out the suture from one end of the wound (Fig. 
190). 

The Twisted or Hare-lip Suture. — This is a very 
useful form of suture where great accuracy and firmness 
of apposition of the edge< of the wound 
are desired. It is applied by thrusting Fig. 191. 

pins or needles deeply through both lips 
of the wound, the edires being kept in 
contact over the wound by figure-of-eight 
turns with silk or wire (Fig. 191 }. The 
ends of the pins should be cut off with pin- 
cutters after the sutures are applied, or Twisted or hare-lip 
should be protected by pieces of cork or suture, 

plaster to prevent them from injuring the 
skin of the patient and causing him pain. The twisted or 
hare-lip suture is frequently employed in plastic opera- 
tions about the face and in other parts of the body where 
accurate apposition of the flaps is important. 

Mattress or Quilt Suture. — This suture is applied by 
carrying the needle through the two flaps and then back 
again, so that a loop is left on one side and the two ends 
of the suture project from the opposite flap (Fig. 192). 
This variety of suture may be applied as an interrupted 
or as a continuous suture; in the latter, loops are made 
through the flaps on each side of the wound. 

Continuous Mattress Suture. — This variety of suture, 
known as the Cushing suture, is often employed as an 
intestinal suture, but does not result in as secure or close 




228 



MIXOR SURGERY. 



apposition of the edges of the wound as the interrupted 
mattress suture. It is applied as shown in Fig. 193. 



Fig. 192. 



Fig. 193. 





Mattress suture, interrupted. (Brewer.) Cushing suture. (Brewer.) 

The Quilled Suture. — In making use of this suture, a 
needle armed with a double thread of wire or silk is 

Fig. 194. 





The quilled suture. (Smith.) 



passed through the tissues as in applying the interrupted 
suture, but at a greater distance from the edges of the 



SUTURES. 



229 




Fig. 195. 



wound. Into the loops on one side of the wound is inserted 
a quiil or piece of a flexible catheter or bougie, and on the 
opposite side the free ends of the sutures are tied around a 
similar object after being tightened (Fig. 194). This form 
of suture makes deep equable pressure along the whole 
line of the wound. In applying this suture, it may be 
found advisable in some cases to introduce a few super- 
ficial interrupted sutures along the line of the wound to 
secure accurate approximation of the 
skin. Two small rolls of sterilized 
or antiseptic gauze may be used as a 
substitute for the quills or pieces of 
catheter, as shown in Fig. 195). 

Button or Plate Suture. — This 
suture is applied by passing a needle 
armed with a double thread as in 
the case of the quilled suture, the 
ends of the suture being passed 
through the eyes of a button or 
through perforations in a lead plate 
before being threaded in the eye of 
the needle. After the suture pre- 
pared in this way has been passed 
through both sides of the wound, the 
needle is removed and the free ends 
of the suture are passed through the 
eyes of a button or the perforations in a lead plate on the 
opposite side of the wound, and are tightened and secured 
(Fig. 196). In applying this form of suture, small rolls 
of antiseptic gauze may be used instead of buttons, as 
shown in Fig. 197. This form of suture may be employed 
in deep wounds to accomplish the same purpose as the 
quilled suture. It allows the cutaneous margins of the 
wound to remain free from compression, and here, as in 
the case of the quilled suture, a few interrupted sutures 
may be introduced between the button or plate sutures to 
secure accurate apposition of the skin surfaces if desired. 
Shotted Suture. — This suture receives its name not 
from any special method of application, but solely from 



Modified quilled suture. 
(Park.) 



230 



MINOR SURGERY. 



the way in which it is secured ; any of the previously 
mentioned varieties of sutures may be employed. The ma- 
terial used in applying this suture may be catgut, silver 
wire, silkworm-gut, silk, or horsehair, and after the suture 
has been passed the needle is removed, and the ends are 
passed through a perforated shot ; the ends are then drawn 
upon to bring the edges of the wound in contact, and the 
shot is pressed down to the skin and clamped by means of 
a shot-compressor. The suture is then cut off flush with 
the surface of the shot. 

This method of securing sutures is especially useful in 



Fig. 196. 



Fig. 197. 





Button suture. (Smith.) 



Modified plate suture, using gauze pledgets. 
Park.) 



closing wounds in the mucous cavities, such as the vagina, 
rectum, and mouth, where the knot or twist of the wire 
might cause irritation of the surface or pain to the patient ; 
it is also a useful method of securing sutures in plastic 
operations ; it also facilitates the removal of the sutures, as 
the shot is not apt to be obscured by the swollen tissue, 
and is easily seized by forceps when the loop is divided. 

Removal of Sutures. — "Where sutures are buried in 
the tissues or used to approximate parts in cavities which 
are subsequently closed, such materials should be used for 
sutures as will be absorbed in a few days, or will become 
encysted, and remain harmless in the tissues — such as cat- 



SUTURES. 



231 



gut, silkworm-gut, or silk — and it is needless to state that 
sutures used with this end in view should be rendered per- 
fectly aseptic before being employed. 

Catgut sutures, when well prepared and used for sutures 
in external wounds, usually undergo absorption in from 
ten to fifteen days ; the loop buried in the tissues is ab- 
sorbed, and the knot may be removed from the surface 
with forceps or it may come off with the dressings. 

The other substances, such as silk, silkworm-gut, silver 
wire, and horsehair, are removed by cutting one side of 
the loop and making traction upon the knot of the suture 
with forceps, or in the case of the wire suture, after divid- 



Pig. 198. 



Fig. 199. 




Lembert's suture. (Bryant.) 



Lembert's suture, a, serous ; b, muscu- 
lar: and, c, mucous coat. (Smith.) 



ing the loop and straightening out one end of it, the wire 
should be withdrawn in a curved direction. 

Sutures which are not causing irritation should be al- 
lowed to remain until the wound is solidly healed. The 
time usually required for their retention in cases of aseptic 
wounds is from eight to twelve days. 



Intestinal Sutures. 

Lembert's Suture. — Lembert's suture is used in wounds 
of the viscera covered by the peritoneum, with the object 
of bringing in contact the peritoneal surfaces. This form 



232 MINOR SURGERY. 

of suture is usually employed in closing wounds of the 
intestine, bladder, or stomach. 

A needle armed with a fine catgut or silk thread is 
passed, and it is better to employ a round needle, such as 
the ordinary sewing-needle, in preference to the bayonet- 
pointed needle, as there results by its use less bleeding 
from the punctures. The needle is first carried through 
the peritoneal and muscular coats of the intestine a short 

distance from the wound, and 
Fig. 200. it is then carried across the 

wound and passed through the 
same portions of the intestine a 
short distance from the edge of 
the wound on the opposite side 
(Fig. 198), and when the suture 
is tightened the peritoneal sur- 
faces of the intestine are inverted 
and brought into contact with 
each other (Fig. 199) ; the inter- 
rupted or continued suture may 
be employed in making this 
form of suture. 

Halsted's quilt suture for intestine. Halsted'S MattreSS Or Quilt 

Suture. — This is a modifica- 
tion of Lembert's suture. The needle penetrates the 
peritoneal and muscular coats of the gut, including a 
small portion of the submucosa, twice on each side of 
the wound, and is then tied (Fig. 200). 

Purse-String Suture. — This form of suture is frequently 
used in operations upon the intestines and other abdominal 
viscera, for covering in the stump of an appendix and in 
operations upon the gall-bladder, and in securing the two sec- 
tions of the Murphy button. It is applied by introducing a 
continuous suture of silk or catgut in a circular manner at 
a little distance from the part to be covered in, the stitches 
pick up the peritoneal and muscular coats at intervals, and 
when the part has been circumscribed by tying the ends of 
the suture, the parts are puckered and bring the serous sur- 
face in contact over the part to be included (Fig. 201). 




SUTURES. 



233 



Czerny Suture. — This suture is applied in intestinal 
wounds by passing the needle armed with a catgut or silk 
thread through the serous membrane on one side of the 
wound of the intestine and out at the wound surface so as 
not to include the mucous membrane ; the needle is then 
passed through the wound surface on the opposite side, 
avoiding the mucous membrane, and brought out through 
the serous membrane a short distance from the edge of 
the wound. By this suture the lips of the wound are 
approximated. For additional security in preventing 

Fig. 201. 




Purse-string suture applied to cover in stump of appendix. 

escape of the contents of the intestine and to secure ap- 
proximation of the serous surfaces a few Lembert sutures 
should be introduced. 



LIGATURES USED IN THE TREATMENT OF VAS- 
CULAR GROWTHS. 

Various forms of ligatures are used for the strangula- 
tion of vascular growths ; the material employed is usu- 
ally strong silk or hemp thread, catgut, or silver wire. 



234 



MINOR SURGERY, 



The Single Ligature with a Pin. — This is applied by 
first inserting a hare-lip pin through the skin near the edge 
of the growth, passing it under the growth and bringing 
it out through the skin at a point opposite the place 
of entry ; a strong silk or hemp ligature is passed under 
the ends of the pin surrounding the base of the tumor, and 
is drawn tight enough to strangulate the growth, and is 
secured by two knots (Fig. 202). If the growth is of 

Fig. 202. 




Vascular tumor strangulated with pin and ligature. 

considerable size, it is better before applying this ligature 
to introduce a second pin at right angles to the first one, 
and then secure the ligature under the pins. In applying 
these forms of ligature to healthy skin, the patient is saved 
much pain, and the separation of the mass is hastened, by 
cutting a groove in the skin with a sharp knife at the 
point where the ligature is to be applied; the ligature 
when tied is buried in the groove thus made. 



Fig. 203. 




Method of applying double ligature. (Roberts.) 

Double Ligature.— This ligature is applied by passing 
a needle or a needle with a handle, armed with a double 
ligature, through the skin near the growth, and then pass- 



SUBCUTA NEO US LIGA TUBE. 



235 



Fio. 204. 




Method of applying double liga- 
ture and pin. (Bryant.) 



ing it under the tumor and bringing it out through the skin 
at a point directly opposite the 
point of insertion ; the ligature 
is then divided and the needle 
removed. The tumor is strangu- 
lated by tying firmly the corre- 
sponding ends of the ligature on 
each side of the tumor, each liga- 
ture including one-half of the 
growth (Fig. 203). 

The double ligature may also 
be applied by first passing a pin 
under the growth and then pass- 
ing a needle armed with a double 
thread under the tumor at right 
angles to the pin, and after re- 
moving the needle the ends of the 
ligature are tied and the tumor 
is strangulated in two sections 
(Fig. 204). 

Quadruple Ligature. — In applying this ligature, two 
needles carrying a double thread are passed under the 
growth at right angles to each other; or if the handled 
needles be used, they may first be passed in this manner, 
and then threaded with double ligatures, which are carried 
under the growth as they are withdrawn. The needles 
being removed, the surgeon ties two ends of the ligature 
together, and repeats this procedure until the growth has 
been strangulated in four sections. 

Subcutaneous Ligature. — This is applied by intro- 
ducing a needle armed with a ligature through the skin 
near the growth, and carrying it through the subcutaneous 
tissues around the part to be constricted for a short distance, 
then bringing it out through the skin. The needle is again 
introduced through the same puncture, and is again brought 
out through the skin at some distance from the first point 
of exit. It is next introduced through this puncture and 
brought out at a more distant point. In this way the 
growth is completely encircled by a subcutaneous ligature, 



236 MINOR SURGERY. 

which is finally brought out at the point of entrance ; the 
tumor is strangulated by firmly tying together the ends of 
the ligature (Fig. 205). 

If a needle armed with a double ligature is first passed 
under the growth, the ligature is divided, and by passing 
each end of the divided ligature subcutaneously around 

Fig. 205. 




Method of applying subcutaneous ligature. (Holmes.) 

the growth it may be strangulated subcutaneously in two 
sections. 

Erichsen's Ligature. — This ligature is employed to 
strangulate tumors of irregular shape in a number of sec- 
tions. A strong silk or hemp ligature three yards in 
length, one-half of which is stained black, is carried by a 
needle as a double ligature under the growth at various 
points so as to leave a series of loops about nine inches 
long on each side of the tumor (Fig. 206) ; the black loops 
being cut on one side, the white on the other, the ends are 
then firmly tied so as to strangulate the growth in sections 
(Fig. 207). 

Elastic Ligatures. — Ligatures made of India-rubber 
varying from half a line to several lines in thickness are 
often made use of in surgery. They may be employed 
to strangulate growths such as moles or nsevi, or in the 
treatment of fistula?, and are especially useful in the treat- 



ELASTIC LIGATURES. 



237 



ment of those cases of fistula in ano in which the internal 
opening into the bowel is situated high up, as the division 

Fig. 206. 




Method of applying Ericksen's ligature. (Erichsen.) 

of such fistula? by this means is accomplished without 
hemorrhage and with less risk than by the employment 

Fig. 207. 




Erichsen's ligature applied. 



of the knife. In applying elastic ligatures in such cases 

the ligature, after being passed through the fistula bv 

means of a probe, is carried out through 

opening ; the sphincter is next , 

elastic ligature is then firmly tied with two or three knots ; 

the greater the tension made before the ligature is tied 



the internal 
well stretched, and the 



238 MINOR SURGERY. 

the more rapidly will it cut its way out. The smaller 
sizes of rubber drainage-tubes may be substituted for the 
solid rubber ligatures. 



TREATMENT OF HEMORRHAGE. 

The surgeon may be called upon to treat the following 
varieties of hemorrhage : arterial, venous, or capillary; 
and these again are classified according to the time of 
their occurrence, as primary — that is, bleeding which 
occurs at the time the wound is inflicted ; intermediary or 
consecutive, that which occurs within twenty-four or forty- 
eight hours after the reception of the injury, and which 
generally takes place during the period of reaction ; and 
secondary, which usually results from a septic condition of 
the wound, causing a septic arteritis, and occurs usually 
after forty-eight hours, but may occur at any time subse- 
quent to this period until the wound is healed. The 
treatment of hemorrhage is both constitutional and local. 

Constitutional Treatment. — This consists in keeping 
the patient in the recumbent posture and avoiding any 
sudden elevation of the head or arms which might induce 
fatal syncope. Opium is a valuable remedy and should be 
freely used. Ergot, gallic acid, acetate of lead, and tinct- 
ure of iron may also be employed, and stimulants and 
food should be carefully administered ; in extreme cases 
the intravenous injection or infusion of normal salt solu- 
tion should be resorted to. The haemostatic properties of 
gelatin have led to its use by subcutaneous injection in 
various forms of internal hemorrhage. A sterilized aque- 
ous solution, containing 2 per cent, of gelatin in normal 
salt solution, is injected into the loose cellular tissue of, 
the abdominal walls or buttock, about 200 c.c. being em- 
ployed. It has been used in haemoptysis, epistaxis, and 
in intestinal hemorrhage in typhoid fever. 

Local Treatment. — This consists in the adoption of 
various local measures to control the bleeding, which may 
be either temporary or permanent in their action. 



DIGITAL COMPRESSION. 



239 



Temporary Control of Arterial Hemorrhage. 

This may be effected by pressure applied directly to 
the bleeding vessel in the wound or by pressure applied 
indirectly to the main artery between the point of its 
injury and the centre of the circulation, and this pressure 
may be made by the fingers — digital compression — by com- 
presses, or by means of tourniquets. 

Digital Compression. — This constitutes one of the 
most valuable means employed in the temporary control 
of hemorrhage: the finger* is pressed directly upon the 

Fig. 208. 




Digital compression of the femoral artery. 

bleeding vessel, in the wound, or is used to make pressure 
upon the artery from which the bleeding arises at some 
point between the wound and the centre of the circulation 
(Fig. 208). Control of hemorrhage by digital pressure 
can be maintained only for a few minutes, for the fingers 
of the surgeon or assistant soon become tired, so that it 
is employed only until means are adopted for permanent 
arrest of the bleeding. Digital compression of the radial 
and ulnar arteries may be resorted to for the control of 
hemorrhage during amputations of the fingers, of the 
axillary and femoral arteries in amputations at the shoul- 
der-joint and the hip-joint. It is also used to control 



240 MINOR SURGERY. 

hemorrhage from wounds either the result of accident or 
those made by the knife of the surgeon, in which case 
the finger is placed directly upon the divided vessel or is 
employed to hold a sponge or compress firmly in the wound. 
Compresses. — By the use of compresses placed directly 
in the wound or applied to the vessel between the wound 
and the centre of the circulation, the temporary control of 
hemorrhage may be very satisfactorily accomplished. The 
compress which is applied in the wound should be made of 
antiseptic or aseptic gauze, thereby diminishing the chances 
of wound-infection. The compress should be held in 
position by a bandage firmly applied, and is generally 
employed only as a temporary expedient until a more 
permanent means of controlling the bleeding is adopted. 

Fig. 209. 




Petit's tourniquet. 



Tourniquets. — These instruments, which are employed 
for the temporary control of hemorrhage from wounds, are 
of many different kinds. 



ELASTIC CONSTRICTION. 241 

Petit's Tourniquet. — This consists of two metal plates 
connected by a strong linen or silk strap, with a buckle, 
the distance between the plates being regulated by a screw 
(Fig. 209). In applying this tourniquet, a compress or 
roller-bandage is placed directly over the artery to be 
compressed, and may be held in position by a few turns 
of the bandage. The lower plate of the tourniquet is 
placed directly over this pad, and the strap is tightly 
secured around the limb to keep the instrument in place. 
The screw is then turned so as to separate the plates and 
tighten the strap, thus forcing the compress or pad upon 
the artery and controlling its circulation. This instru- 
ment is very generally employed for the control of hem- 
orrhage in wounds of the extremities, and is especially 
useful in amputation of these parts, being placed over 
the main artery some distance above the seat of opera- 
tion. 

The Spanish Windlass. — An improvised tourniquet, 
known as the Spanish windlass, may be employed in cases 
of emergency ; it is prepared by folding a handkerchief or 
piece of muslin into a cravat and placing a compress or 
smooth pebble on the body of the cravat ; this is placed 
over the artery to be controlled, and the ends of the hand- 
kerchief are tied loosely around the limb ; a short stick is 
passed through this loop, and by twisting the stick the loop 
is tightened and the compress is forced down upon the 
artery (Fig. 210). 

Many other forms of tourniquet have been devised which 
have the pad and counter-pad arranged to make pressure 
upon the vessel, such as Lister's aorta compressor (Fig. 
211), which is employed in the treatment of aneurism of 
the iliac vessels and for the control of hemorrhage in ampu- 
tation at the hip-joint. Signorini's tourniquet (Fig. 212) 
is constructed upon the same principle, and is frequently 
employed to control the circulation in the femoral artery 
in cases of operations on the thigh and leg and in the 
treatment of femoral or popliteal aneurism. 

Elastic Constriction. — The elastic tube, or the strap 
of Esmarch's apparatus (Fig. 213), may also be employed 

16 



242 



MINOR SURGERY. 



for the temporary control of arterial hemorrhage, being 
applied above the wound ; and if it is not at hand, any 

strong rubber cord or a piece of 
Fig. 210. large-sized drainage-tube may be 

used as a substitute. Elastic sus- 
penders or garters may also be 
employed in an emergency. In 
hemorrhage from wounds of the 
hands and feet, especially in chil- 

Fig. 211. 





The Spanish windlass. 



Lister's aorta compressor. 



dren, and in controlling hemorrhage from wounds of the 
penis, a piece of drainage-tube, firmly applied above the 
wound, may be employed with advantage. Care should be 
observed in applying elastic constriction, for if the elastic 
tube be applied too tightly, the subcutaneous tissues may be 
divided or nerves may be so compressed that their func- 
tion is destroyed. The tube or strap, although generally 
employed to control hemorrhage from vessels of the 
extremities, may be used to control the femoral artery 
as it crosses the brim of the pelvis, by placing a com- 
press over the artery in this position, and then applying 
the elastic band to secure it by making a figure-of-eight 
turn, passing under the thigh, crossing over the pad, and 



ESMARCH'S BANDAGE AND TUBE. 



243 



Fig. 212. 



then carrying the ends around the pelvis, and securing 

them. 

To make pressure on the axillary artery, a compress 

should be placed in the axilla, and the middle of the tube 

placed over this to hold it in 
position ; the ends of the tube are 
then carried over the shoulder, 
where they are crossed, and 
then carried to the opposite 
axilla and secured. 

Fig. 213. 





Signorini's tourniquet. 



Elastic strap of Esmarch's apparatus. 



Haemostatic Forceps. — The temporary control of arte- 
rial hemorrhage by the use of haemostatic forceps is now 
very generally employed in surgical operations, and their 
use has done much to diminish the shock following opera- 
tions from the loss of blood. The haemostatic forceps in 
general use is self-retaining ; it is clamped upon the bleed- 
ing vessel, and is allowed to remain until the operation is 
completed, when the vessel is secured permanently by the 
application of a ligature, and the forceps is removed. 
The use of these forceps will be found very satisfactory 
in controlling hemorrhage during the removal of tumors ; 
in amputations, and for the temporary control of bleeding 
during the operation of tracheotomy, they will be found 
most efficient, as also in abdominal operations, in which 
their utility was first demonstrated (Fig. 214). 

Esmarch's Bandage and Tube. — This apparatus, 



244 



MINOR SURGERY. 



which is applied to the limbs to render them blood- 
less during operations, 
Fig. 214. consists of a rubber band- 

age two and a half inches 
in width and three or four 
yards in length, and a rub- 
ber tube two yards in length, 
to one end of which is 
attached a chain and to the 
other a hook, or, better, a 
rubber strap, one inch in 
width and one and a half 
yards in length, with a hook 
and chain. The bandage is 
applied to the extremity of 
the limb, and is carried up 
the limb to a point some 
distance above the seat 
of proposed operation ; the 
bandage is applied firmly, 
each turn overlapping one- 
fourth of the preceding one, 
and when the last turn has 
been made the rubber tube 
Haemostatic forceps. or strap is wound firmly 

around the limb and secured 
by fastening the hook into one of the links of the chain 
(Fig. 215). After securing the tube or strap, the rubber 
bandage is removed from the limb ; and if the tube has 
been sufficiently firmly applied, the limb will be found 
blanched, and should be free from blood during the opera- 
tion. Care should be taken not to apply the tube or 
strap too tightly upon poorly developed limbs, or on parts 
of the limb where large nerve-trunks approach the sur- 
face, as they may be subjected to an amount of pressure 
which will interfere with their functions subsequently. 
I have knowledge of one case of this nature in which 
permanent paralysis of the limb followed the use of 
Esmarch's apparatus; the tube should be applied with 




POSITION. 



245 



just sufficient firmness to control the circulation. As the 
strap, when firmly applied, completely cuts off the circu- 
lation of the parts below, it should be applied for as short 
a time as possible, as gangrene has resulted from its pro- 
longed use. After removal of the tube or strap there is 
generally free capillary hemorrhage, due to paralysis of 
the vasomotor nerves from pressure, but this in a short 
time stops. This appliance is of the greatest service in 

Fig. 215. 




Esmarch's bandage and tube applied. 

controlling hemorrhage at the time of operation, and in 
amputations and for removal of vascular tumors from the 
limbs will be found most satisfactory. In operations upon 
bones, such as resection or sequestrotomy, it is especially 
useful, as it allows the surgeon to inspect the parts unob- 
scured by hemorrhage. I have found its use most satis- 
factory in operations for the removal of foreign bodies, such 
as needles embedded in extremities. 



Permanent Control of Arterial Hemorrhage. 

To secure this end, the surgeon may resort to the use of 
position, cold, heat, styptics, pressure, cauterization, liga- 
tion, torsion, suture of the artery, or acupressure. 

Position. — In arterial hemorrhage from wounds of the 
extremities, elevation of the part will be found to mate- 
rially diminish the amount of bleeding ; in hemorrhage 
from wounds of the arteries of the hand, forearm, foot, or 



246 MINOR SURGERY. 

leg, forcible flexion of the forearm on the arm or of the leg 
on the thigh will be found useful in diminishing the force 
of the blood-current. 

Cold. — The application of cold by means of a stream 
of cold water or an ice-bag or pieces of ice will often be 
found an efficient means of controlling hemorrhage from 
vessels of small calibre ; it is especially applicable to hem- 
orrhage from wounds of the vessels of the mouth, nostrils, 
vagina, or rectum. 

Hot Water. — Hot water will be found a very efficient 
means of controlling hemorrhage from small vessels, and 
it may be used in the form of a hot antiseptic solution. It 
is of especial value in capillary or parenchymatous hem- 
orrhage, and is employed in the form of a douche or by 
means of sponges or gauze pads dipped in the hot solution 
and packed into the wound. The injection of hot water is a 
most satisfactory method of controlling uterine hemorrhage. 

Styptics. — These agents are sometimes employed to 
control capillary bleeding or hemorrhage from small ves- 
sels, and although their use is often satisfactory as regards 
the control of the bleeding, they have the disadvantage 
of interfering with primary union in wounds, and since 
the value of asepsis in wound treatment has been demon- 
strated they are now very seldom employed. The most valu- 
able styptics are alcohol, alum, oil of turpentine, perchloride 
of iron, persulphate of iron or Monsel's solution, acetic acid, 
vinegar, adrenalin chloride, antipyrin, and gelatin. 

Adrenalin Chloride. — A solution of adrenalin chloride, 
1 part to normal salt solution 1000 parts, has been re- 
cently employed for the control of hemorrhage. It seems 
to be most serviceable in capillary hemorrhage. Adrenalin 
extract, in the form of powder, may also be dusted upon 
a bleeding surface to secure haemostasis. 

Antipyrin. — A solution of antipyrin, 5 per cent., in steril- 
ized water possesses marked styptic action. As it also pos- 
sesses antiseptic properties and is not toxic, it may be used 
to control capillary bleeding from the surface of the brain, 
the intestines and peritoneum, and from the bone-cavities. 

Gelatin. — This may be used as a styptic where it can 



PRESSURE. 247 

be applied locally in a 5 to 10 per cent, solution in normal 
salt solution. It may be applied by injecting, irrigating, 
or tamponing the bleeding area. It has been employed 
successfully in epistaxis, hsematemesis, vesical and uterine 
hemorrhage, and in superficial wounds in patients the 
subjects of haemophilia. 

Pressure. — For the permanent control of arterial hem- 
orrhage, pressure may be applied directly to the bleeding 
point or surface by means of a compress of antiseptic gauze 
or by strips of gauze packed firmly into the cavity from 
whose surface the bleeding arises. 

Compresses are used with the best results where the 
proximity of a bone gives a firm substance upon which 
the vessel may be compressed, as is the case in the vessels 
of the scalp. Pressure applied by means of packing with 
strips of gauze will be found most efficient in controlling 
hemorrhage from cavities, such as the nose, vagina, or 
rectum, and in the cavities resulting from the removal of 
necrosed or carious bone. Pressure may be indirectly 
applied to an artery by flexing the joint over a compress 
or by firm bandaging of the limb. 

. In controlling bleeding from a divided artery in a bony 
cavity, such as the inferior dental, a piece of catgut liga- 
ture may be forced into the canal, and will control the 
bleeding in a most satisfactory manner, or it may be 
controlled by forcing a small piece of Horsley's wax into 
the opening in the bone ; this wax is composed of wax, 7 
parts; oil, 2 parts; and carbolic acid, 1 part. 

Halsted has introduced a material known as gut wool, 
which is prepared from the same material from which cat- 
gut is made. This is cut into fine shreds, and is used to 
control hemorrhage from bone, being pressed into the open- 
ing or cavity in the bone from which the bleeding arises. 

The troublesome hemorrhage sometimes occurring after 
the removal of a tooth may be controlled by packing the 
alveolar cavity with a strip of iodoform gauze, or by 
introducing a wedge-shaped piece of cork and holding 
it in place by fastening the jaws together by means of 
a bandage. 



248 MINOR SURGERY. 

Cauterization. — The use of cauterization by means of a 
hot iron is a satisfactory method of arresting hemorrhage. 
Care should be taken to have the iron only of a dull-red 
or black heat, as the result desired is not the destruction 
of the tissues, but the coagulating effect of heat upon them. 
The form of cautery-iron employed will depend upon the 
size and position of the vessel. Paquelin's cautery is also 
a satisfactory apparatus to use for the control of hemor- 
rhage. 

The control of arterial bleeding by cauterization is often 
resorted to in operations upon the jaws and in the removal 
of tumors from the mouth or pharynx or of the tonsils ; 
it is also frequently employed to control hemorrhage in 
operations upon the uterus and the rectum, and also that 
resulting from the removal of abdominal tumors, where 
the application of a ligature is difficult and often impos- 
sible. 

Torsion. — This method of controlling arterial hemor- 
rhage consists in seizing the end of the artery, drawing it 
slightly out of its sheath and twisting it ; it may be accom- 
plished with a single pair of forceps or haemostatic forceps, 
or by two pairs of forceps. In the latter method the 
vessel is held by one pair of forceps and is twisted by the 
second pair. 

Torsion of arteries in accidental wounds is quite com- 
mon, and in many cases controls the hemorrhage until sur- 
gical aid is rendered. I have seen hemorrhage from the 
femoral artery in Scarpa's triangle completely controlled 
in this manner in a case of avulsion of the thigh from a 
railway injury. 

Fig. 216. 




Double-spring artery forceps. 



In vessels of moderate size it may be practised with one 
pair of forceps, and the ordinary double-spring artery for- 
ceps (Fig. 216) or haemostatic forceps will be found satis- 



DEEP SUTURES. 



249 



factory for such cases. In larger arteries two forceps should 
be employed, or some of the numerous forms of torsion 
forceps which have been devised for this purpose. 

Ligation. — The use of the ligature is by far the most 
generally employed method of controlling arterial hemor- 
rhage. The materials used are silk, hemp thread, or cat- 
gut. Catgut or silk is the material generally employed. 

Fig. 217. 




Tenaculum. 

The vessel is seized with a pair of artery or haemostatic 
forceps or a tenaculum (Fig. 217) and drawn out of its 
sheath, and a ligature of sterilized catgut or silk is thrown 
around it and secured by a surgeon's knot, or by a reef 
knot and a surgeon's knot combined, and when firmly 
tied the ends of the ligature are cut short in the wound. 

Fig. 218. 




Aneurism needle armed with ligature. 

When ligatures are applied to vessels in their continuity, 
they may be threaded into an eyed probe or aneurism needle 
(Fig. 218) and carried around the vessel and secured. 

Deep Sutures. — A convenient method of applying a 
ligature to a bleeding point in a deep wound, or to a vessel 
in tissues which are of such a nature as not to permit of 
the isolation of the vessel, is to use a curved needle 
threaded with a catgut ligature, which is passed deeply 



250 MINOR SURGERY. 

into the tissues near the vessel and brought out on the 
opposite side ; the ligature thus placed is then firmly tied, 
and the ends are cut short in the wound (Fig. 219). 

Fig. 219. 




Artery occluded by suture. (Esmaech.) 

Suture of Arteries. — Wounds of arteries, both longi- 
tudinal and transverse, have been successfully closed by 
sutures both in man and the lower animals. It is recom- 
mended in the larger arteries, where more than two-thirds 
of the circumference has been divided, to resect the injured 
portion of the vessel, where it can be done without remov- 
ing more than three-fourths of an inch of the vessel, and 
invaginate one end into the other, and to secure their fixa- 
tion by fine silk or catgut sutures. In longitudinal wounds 
the edges may be brought together by fine silk sutures, in- 
troduced by means of a fine cambric needle. The sutures 
should be inserted from one-sixteenth to one-twentieth of 
an inch apart, and one-sixteenth of an inch from the edges 
of the wound, and should include only the adventitia and 
media, not perforating the intima. During the operation 
the circulation in the vessel should be controlled both 
above and below the wound by forceps covered with 
rubber tubing. Where a distinct sheath is present, it 
should be sutured over the w r ound ; and if this is not 
present, muscle or fascia should be sutured over the closed 
wound in the vessel. The application of sutures to wounds 
of arteries has been advocated, to secure permeability of 
the vessel at the seat of the wound, but it is still a mooted 



ACUPRESSURE. 



251 



question whether the vessel remains ultimately permeable 
at the seat of the wound. 

Closure by Plaster Tape. — Brewer, in experiments upon 
wounds of the arteries in animals, has secured control of 
the bleeding and closure of the wound by wrapping around 
the wounded vessel a strip of specially prepared adhesive 
plaster. The plaster is a variety of rubber plaster which 
has been thoroughly sterilized, so that it can remain indefi- 
nitely in the tissues. He has suggested that this procedure 
may be employed in wounds of the larger arteries in man, 
where for any reason sutures cannot be applied. 

Acupressure. — In this method of controlling arterial 
hemorrhage a needle or pin is used, which is thrust 



Fig. 220. 



Fig. 221. 





Acupressure — first method ; raw Acupressure— first method : cutaneous 

surface. (Erichsen.) surface. (Erichsen.) 



through the tissues in such a way as to compress the artery. 
In the first method, of acupressure the surgeon places a 
finger of his left hand upon the mouth of the bleeding 
vessel, and with his right hand introduces the needle from 
the cutaneous surface and passes it through the thickness 
of the flap until its point projects for a couple of lines or 
so from the surface of the wound a little to the right side 
of the end of the vessel. By forcibly inclining the head 
of the needle toward his right, he brings the projecting 
portion of its point firmly down on the side of the vessel, 
and after seeing that it occludes the artery he makes it 
re-enter the flesh as near as possible to the left side of the 
wound and pushes the needle through the flesh until its point 
comes out again at the cutaneous surface (Figs. 220 and 221). 



252 MINOR SUBGEBY. 

There are a number of methods of using: the needle or 
pin in acupressure to produce occlusion of the vessel, but 

as this method of arresting hemorrhage is not often em- 
ployed at the present time they need not be described. 

Rules for Ligating Wounded Arteries. — The follow- 
ing rules for the application of ligatures to wounded 
arteries have been recommended by Ashhurst : 

1. In cases of primary hemorrhage, no operation should 
be performed upon an artery unless it is at the moment 
actually bleeding. The exception to this rule is in the 
cases where the vessel is seen to pulsate in the wound, or 
where the wound involves the region of a large artery and 
the patient has to be transported or may be in a position 
not to receive surgical aid subsequently if needed ; under 
these circumstances, the vessel should be tied or the 
wound should be explored to ascertain the fact that no 
important vessel has been injured. 

2. In applying a ligature to a wounded artery, the 
surgeon should cut down directly upon it at the point from 
which it bleeds and secure it in the wound. This rule 
holds good for both primary and secondary hemorrhage. 

3. Two ligatures should be applied, one to each end of 
the artery if it be completely divided, and one on each 
side of the wound if the latter has not severed all the coats 
of the artery. This procedure is adopted for the reason 
that arterial anastomosis is so free that the proximal liga- 
ture will not always, even temporarily, arrest the bleeding ; 
and if it does accomplish this object at the time, after the 
collateral circulation is established bleeding is apt to occur 
from the distal extremity of the divided vessel. If the 
coats of the artery are not completely severed, their divis- 
ion should be completed, either before or after the appli- 
cation of the proximal and distal ligatures, thereby favor- 
ing contraction and retraction of the ends of the divided 
vessel. 

Treatment of Venous Hemorrhage. 

Bleeding from small veins often stop^ spontaneously 
unless there is pressure upon the wounded veins on the 



_ : : 



-i :- : .:_: : :t- 
„,._- -, r ;-, ^ --_ 

application of an 

rVi: :i- L" :_■-: ~~- 

-::,-" - :i- 2: 
— ---/-•• ; 71 -: - 

The Lateral U 
ligature to small 

Tenons sinuses, ha 



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of a ligature : if 

rll - — :- 11 
:~- l : : n : :i- 
eontrolled by the 

— 11- : --- tz. : _- 



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- - - 



7:-- 



ployed with good results ; 
this procedure consists in 
pfaienine op the wall of 
the vein so as to include 

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and thro wing a delicate 
^•-■::t r: n. . :: 7:_ 

Suture of Veins — 

7i:- 71 •-:::- i - Ls 
been employed with suc- 
cess in the case of the 

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:: i -i i : '- :-:ii7 '."_-•: 
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:i ':• :i -; — : :':- :i : 

should be dosed by fine silk 
" ;i-i . 7 ii --H - : i. - ■; 
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the advantage of eootrollni 
-:n- i : :•:. :~i: - . '.t-tit: i 
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by pressure or the ligature 




u. : 



lie: . s-> 



254 MINOR SURGERY. 

Compression by means of strips of sterilized gauze is 
often employed to control venous hemorrhage from cavi- 
ties. 

Treatment of Capillary Hemorrhage. 

Capillary or parenchymatous hemorrhage is often 
arrested spontaneously on exposure of the surface of the 
wound to the air, but the bleeding may not be controlled 
and may be so profuse that its arrest becomes a matter 
of importance. To control this form of bleeding, pres- 
sure may be applied to the bleeding surface for a short 
time, and if this fails to arrest it, sponging the surface 
with dilute alcohol will sometimes prove satisfactory ; but 
the best application to arrest hemorrhage of this nature 
is hot water, which may be used in the form of a hot 
bichloride solution or antipyrin solution. 

Adrenalin chloride, 1 part to normal salt solution 1000 
parts, or a 5 to 10 per cent, solution of gelatin in normal 
salt solution, may be employed. 

Acetic acid and vinegar are also sometimes employed 
for the same purpose. In cases where the means men- 
tioned above fail to control the bleeding, it may be neces- 
sary to pack the wound with strips of antiseptic gauze ; 
this dressing is most serviceable when the hemorrhage 
comes from cavities such as result from the removal of 
tumors or excisions of joints, and for the control of bleed- 
ing following the removal of necrosed or carious bone. 
To control hemorrhage from mucous cavities, such as the 
nose, rectum, and vagina, this method of treatment is also 
frequently resorted to. 

Treatment of Secondary Hemorrhage. 

Secondary hemorrhage following the use of the ligature 
or other means of controlling bleeding, usually results 
from a septic condition of the wound, and is due to a septic 
arteritis. Since the adoption of the antiseptic and aseptic 
methods of wound treatment it is a much less frequent 
complication of wounds. 



EPISTAXIS. 255 

The treatment of this complication is both constitu- 
tional and local. The constitutional treatment consists in 
the use of those remedies which were mentioned as ser- 
viceable in primary hemorrhage, and the drugs upon 
which most reliance should be placed are opium and ergot. 

The local treatment of this form of hemorrhage consists 
in the use of the various means of controlling hemorrhage 
which have been mentioned, such as the ligature, hot water, 
pressure, or the actual cautery. If possible, it is well to 
secure the vessel from which the bleeding arises in the 
wound ; if for any reason this cannot be done, the main 
artery should be ligated above the wound if the hemor- 
rhage be arterial. 

Control of Hemorrhage from Special Parts. 

Epistaxis, or hemorrhage from the nose, may be so pro- 
fuse as to require surgical interference. To control this 
form of hemorrhage, the application of iced compresses to 
the surface of the nose may first be made use of, or the 
injection of cold sterile water or adrenalin solution. If 
this fails to control the bleeding, the surgeon or the patient 
should grasp the cartilaginous portion of the nose with his 
thumb and forefinger in such a manner as to keep the nos- 
trils tightly closed, which will prevent the passage of air 
through the nose and thus permit clots to form, arresting 
the flow of blood. Bleeding from the nose often arises 
from the erosion of a small artery low down upon the sep- 
tum, which can be freely exposed by introducing a nasal 
speculum, and the bleeding point may be touched with a 
cautery-iron, thus avoiding the necessity of plugging the 
nares. If these simple means fail to arrest the bleeding, 
the nasal cavity or cavities may be packed with strips of 
antiseptic gauze introduced into the anterior nares, and 
pushed backward by a director or probe ; this will often 
be found a satisfactory means of arresting the bleeding. 
This method may be supplemented by a plug of antiseptic 
cotton introduced into the posterior nares with the finger. 
The use of a rubber tampon, consisting of a rubber bag, 



256 MINOR SURGERY. 

introduced into the nares in a collapsed state and after- 
ward inflated, has also been recommended for the control 
of this variety of hemorrhage. 

Another method of controlling hemorrhage from the 
nose consists in introducing a small piece of sponge or 
pledget of sterilized gauze, tied to a strong silk ligature, 
into the anterior nares and pushing it back along the floor 
of the nose to the posterior nares ; a piece of sponge 
or gauze about the size of a marble, with a hole in the 
centre, is threaded on the ligature and pushed back until 
it comes in contact with the first piece introduced, and thus 
by introducing a number of pieces of sponge or gauze in 
this way the nasal cavity may be completely filled and 
the bleeding arrested. Care should be taken to see that 
the sponge has been rendered aseptic before being intro- 
duced, and the nasal cavity should be washed out with an 
antiseptic solution before its introduction. The sponges 
or gauze may be allowed to remain for twenty-four to 
forty-eight hours (Fig. 223). 

Plugging the nares by means of Bellocq's canula is also 
employed to arrest hemorrhage from the nasal cavities ; 
the canula, armed with a strong ligature, is passed along 
the floor of the nose until it reaches the pharynx, when 
the spring being protruded, the ligature is seized and 
brought out of the mouth and secured to a plug of lint or 
of antiseptic gauze of the required size, and upon with- 
drawing the instrument the plug is brought into position 
in the posterior nares and the end of the ligature allowed 
to protrude from the mouth to facilitate its removal (Fig. 
224). An ordinary flexible catheter may be employed in- 
stead of Bellocq's canula for the introduction of the liga- 
ture. 

Hemorrhage from the Urethra. — In hemorrhage from 
the urethra, if profuse, the blood will trickle from the 
meatus ; or if efforts at micturition are made, the first por- 
tion of urine will contain blood, but afterward will be clear, 
and the last portion will contain a few drops of pure blood. 

This variety of bleeding, if it proceeds from the ante- 
rior portion of the urethra, may be controlled by the 



EPISTAXIS. 
Fig. 223. 



257 




Plugging the nares from the front. (Roberts.) 
Fig. 224. 




■s:i^4 



17 



Plugging the nares with Bellocq's canula. (Fergusson.) 



258 MINOR SURGERY. 

introduction of a catheter and the application of a band- 
age around the penis applied so as to make only moderate 
pressure. 

If the bleeding comes from the posterior portion of the 
urethra, it will often be controlled by .the application of 
cold or pressure to the perineum, or by the introduction 
of a cold steel bougie, or by the injection of a weak solu- 
tion of antipyrin or of adrenalin solution. 

Hemorrhage from the Bladder. — In this variety of 
hemorrhage the first portion of the urine may be blood- 
stained, and the last portion will contain more blood and 
clots as the organ contracts, which distinguishes it from 
hemorrhage from the kidneys, in which admixture of blood 
with the urine renders it of a smoky color, or dark red if 
the bleeding is profuse. 

To control bleeding from the bladder, a catheter should 
be introduced and the urine and clots withdrawn ; the 
bladder should next be washed out with a warm or cold 
boric acid solution. In severe cases a weak solution of 
tannic acid, antipyrin, alum, or adrenal solution may be 
employed. The application of ice to the perineum, and 
suprapubic regions may also be employed with advantage. 

Hemorrhage from the Rectum. — This variety of 
bleeding may be controlled by the injection of cold or 
astringent enemata. If the bleeding be profuse, a speculum 
should be introduced, and when the source of the bleed- 
ing has been discovered the actual cautery or a ligature 
should be applied. If this is not feasible, the rectum may 
be plugged with strips of antiseptic gauze, or a piece of 
a rubber catheter of large calibre may be wrapped with 
gauze and introduced into the rectum, the end of the 
catheter being allowed to protrude ; by using this tube 
flatus can escape, and if the bleeding is not controlled 
blood will escape through the tube, preventing the risk 
of concealed hemorrhage. If the bleeding arises from 
hemorrhoids or polypus of the rectum, operative treatment 
of these conditions should be undertaken to remove the 
cause of bleeding. 



ACUTE ABSCESS. 259 

TREATMENT OF ABSCESS. 

In operations for evacuation of the contents of abscesses 
care should be taken to observe every precaution to pre- 
vent a new infection of the wound or abscess cavity ; the 
skin over the abscess should be carefully cleaned to make 
it aseptic, the hands of the surgeon and the instruments to 
be brought in contact with it should also be aseptic. 
These precautions should be especially observed in the 
opening of chronic abscesses when a new variety of infec- 
tion is liable to be introduced if aseptic precautions are not 
rigidly observed. 

Acute Abscess. — This variety of abscess should be 
opened by incision, and this is best done with a straight, 
narrow, sharp-pointed bistoury. The incision should be 
deep enough to expose freely the cavity of the abscess, 
and should be parallel with and not across important 
structures, and it should also be made at as dependent a 
portion as possible. Abscesses of the limbs are opened by 
a longitudinal incision, and those in the region of the anus 
and breast by an incision radiating from the anus or nipple. 

Hilton's Method. — In deep-seated abscesses in the region 
of important structures the method of opening suggested 
by Mr. Hilton may be employed with advantage: it con- 
sists in making a small incision through the skin and 
cellular tissue; a director is next pushed through the tis- 
sues into the abscess cavity, which will be shown to have 
been reached by the escape of pus along the director; a 
dressing-forceps with the blades closed is now pushed 
along the director into the abscess cavity, and when this 
has been accomplished the director is withdrawn and the 
forceps removed with the blades expanded so as to 
dilate the wound and allow the pus to escape. Pressure 
should not be made upon the walls of the abscess to empty 
it, as by so doing delicate vessels may be ruptured and 
cause hemorrhage, and the spread of the infection may 
be facilitated. 

The cavity of the abscess having been emptied of pus, 
it may be irrigated with a stream of carbolic or bichlo- 



260 MINOR SURGERY. 

ride solution, or the irrigation of the cavity mav be 
omitted, and if the cavity is not very large or deep, no 
drainage-tube need be introduced, and a small piece of 
protective may be placed between the lips of the wound 
to prevent their adhesion ; but if, on the other hand, the 
cavity is extensive and deeply situated, a rubber drainage- 
tube or a strip of iodoform or sterilized gauze should be in- 
troduced to the bottom of the cavity to secure free drainage, 
and if a tube be used, it should be fixed at the surface of the 
skin by a safety-pin. A gauze dressing, consisting of a 
number of layers, which has been moistened in carbolic or 
bichloride solution, is next placed over the wound, and is 
covered by a number of layers of dry gauze, which are in 
turn covered by a piece of rubber tissue. The latter may 
be substituted by a few layers of sterilized or bichloride 
cotton, and the dressing is finally secured by a roller- 
bandage. The dressing is removed at the end of two or 
three days, the cavity being washed out with one of the 
antiseptic solutions previously mentioned. The drain- 
age-tube may then be shortened or removed, and the 
dressings reapplied, as at the primary dressing. Under 
this method of treatment acute abscesses usually heal 
promptly. 

Chronic or Tuberculous Abscess. — This variety of 
abscess, which occurs chiefly in connection with diseases 
of the bones or joints or of the lymphatic system, is 
tubercular in origin, and may be opened in various ways, 
the time at which this should be done depending upon 
the size and situation of the abscess and the amount of 
constitutional and local disturbance which the patient ex- 
periences from its presence. 

Aspiration. — A tuberculous abscess may be evacuated by 
means of the aspirator ; the pus being withdrawn as far as 
possible, the puncture is sealed with a small piece of gauze 
covered with iodoform collodion. Reaccumulation of pus 
often takes place, and the aspiration has to be repeated 
a number of times. The greatest difficult v in the success- 
fnl removal of the contents of tuberculous abscesses by 
means of aspiration is the presence of cheesy masses in the 



CHRONIC OR TUBERCULOUS ABSCESS. 261 

pus, which occlude the canula and often prevent complete 
emptying of the cavity. 

Puncture and Injection. — This variety of abscess may 
also be evacuated by making a puncture through the skin 
and overlying tissues with a narrow bistoury, the surface 
having been previously thoroughly washed with soap and 
water and with a carbolic or bichloride solution ; a direc- 
tor is next pushed through this small wound into the 
cavity of the abscess, and the pus is allowed to escape by 
stretching the wound with the director; when the cavity is 
emptied of pus it is washed out with a carbolic or bichlo- 
ride solution or sterile water introduced into it by pushing 
the nozzle of a syringe into the cavity, and this is allowed 
to escape in the same way as the pus previously did. 
When all the irrigating solution has escaped, the cavity 
may be injected with an emulsion composed of iodoform 
1 part, glycerin 10 parts ; after this has been introduced 
the small wound is closed by a compress of antiseptic 
gauze held in place by a compress of bichloride cotton and 
a bandage or by strips of adhesive plaster. The injection 
of the iodoform emulsion need not be repeated as long as 
iodoform continues to be excreted in the urine. 

In evacuating tuberculous abscesses by means of the as- 
pirator or by a small puncture, there is absence of shock, 
and the loss of blood is insignificant, so that these pro- 
cedures should generally be first employed, and the more 
radical operation of incision and curetting of the cavity 
of the abscess, which is accompanied with a certain amount 
of shock and hemorrhage, should be reserved for those 
cases in which the less severe operations have not been 
followed by a satisfactory result. 

Incision. — Tuberculous abscesses are also treated by 
making a free incision into the abscess cavity with full 
antiseptic precautions, and after the escape of the puru- 
lent matter the walls of the abscess should be thoroughly 
scraped with a curette; after the cavity has been freely 
washed out with a carbolic or bichloride solution or sterile 
water, large drainage-tubes are introduced and an antiseptic 
dressing is applied to the wound. The edges of the in- 



262 MINOR SURGERY. 

cision may be brought together by sutures without the 
introduction of drainage, or the cavity may be packed with 
iodoform gauze and allowed to heal by granulation. The 
dressings are removed as soon as they become soaked, and 
the drainage-tubes are shortened or removed as the dis- 
charge diminishes and the cavity contracts. 

Diffuse Suppuration. — This form of suppuration is 
treated by numerous punctures or incisions, which allow 
the purulent matter to escape ; and where sloughs are pres- 
ent, free incisious may be required to give exit to the 
necrosed tissues ; the introduction of drainage-tubes may 
also be required. The wounds and the cavities, as far as 
possible, should be washed out with sterile water or bichlo- 
ride solution and an antiseptic gauze dressing applied. 

Sinuses. — These are suppurating tracts which result 
from abscesses or wounds. If superficial, they should be 
laid open freely and their surfaces scraped with a curette, 
and then lightly packed with strips of bichloride or iodo- 
form gauze and covered by. an antiseptic dressing. If 
they are too deep to be treated by incision, their healing 
may be facilitated by the injection of stimulating solu- 
tions introduced by means of a syringe ; the employment 
of solutions of chloride of zinc, nitrate of silver ; and sul- 
phate of copper, varying in strength from 5 to 20 grains 
to the ounce of water, will often prove satisfactory. 



SHOCK. 

Shock is a condition of physical depression or prostra- 
tion which often develops after severe injuries or opera- 
tions. Paralysis of the vascular tone in the arteries, with 
coincident feebleness of the action of the heart, causes an 
unequal distribution of the blood, and the balance of the 
circulation is disturbed ; the abdominal veins become dis- 
tended and the right side of the heart becomes engorged, 
the amount of blood in the arteries being correspondingly 
lessened ; the brain and the lungs become anaemic, and if 
the condition persists the action of the heart is arrested. 



SHOCK. 263 

The essential condition of shock is inhibition of nerve 
force and reflex paralysis. Shock may develop immedi- 
ately upon or some time after the reception of the injury. 
Every traumatism is probably followed by a certain amount 
of shock, and, as a rule, its degree is proportionate to 
the severity of the injury received. Yet this rule is 
not without exception ; certain classes of injuries are at- 
tended with marked shock, and the part of the body sus- 
taining the injury will have an important influence upon 
the degree of development of shock. Contusions of the 
viscera, wounds of the testicle, contused and lacerated 
wounds of the trunk and extremities, if extensive and ac- 
companied by free hemorrhage, are usually followed by 
marked and often fatal shock. Gunshot wounds causing 
perforation of important cavities of the body, injuries of 
the viscera, and shattering of the bones are also well recog- 
nized as giving rise to shock in a marked degree. Burns 
and scalds, if they involve a considerable surface of the 
body, are attended with severe shock. 

Diagnosis. — The condition of shock resulting from 
purely emotional causes is usually not profound or pro- 
longed, and can be differentiated from that resulting from 
corporeal injuries by the history of the case. The con- 
dition arising from excessive hemorrhage presents many 
symptoms common to shock, but here the nature of the 
injury will often assist in the diagnosis, and in doubtful 
cases examination of the blood may be of service, for if 
such an examination shows that the red blood-cells are 
considerably diminished, being 3,500,000 or less, it is 
probable that the condition is due to hemorrhage rather 
than shock. Fat embolism may also be confounded with 
shock, but it should be remembered in differentiating the 
conditions that shock usually appears promptly, and the 
symptoms of fat embolism from thirty-six hours to three 
days after the injury. The experimental researches of 
Grile have largely confirmed our clinical observations as 
regards the development of shock in injuries and opera- 
tions in different regions of the body. 

A patient suffering from shock presents pallor of the 



264 MINOR SURGERY. 

surface, paleness of the lips, dilated pupil?, clammy moist- 
ure of the skiu. muscular debility, occasionally relaxation 
of the sphincters, frequent, feeble, irregular pulse, subnor- 
mal temperature, and feeble, short, sighing respiration : in 
many cases extreme thirst is a prominent symptom. The 
senses are often perfectly retained. The temperature is 
always subnormal, and may vary from a point a little 
below the normal to a point below 90° F. (32 c C. . A 
depression below 97 c F. 36° C. . if it persists for a few 
hours, usually indicates a grave condition of shock, and 
reaction may not occur, although it has been observed in 
sases where the temperature was as low as 90 c F. 32 z C. ). 

Prophylaxis. — Unfortunately, many of the worst cases 
of shock are due idents, and here treatment can he 

directed only to the condition of shock itself: but the 
surgeon is often able to diminish t-:> S':>me extent the amount 
of shock following operations by judicious prophylactic 
treatment. In patients in whom shock is apt to be mark- 
edly developed, as in children or feeble or aged subjects, 
or in certain classes of operations, he may give stimulants 
before the operation, and see that the surface of the body 
is not unnecessarily exposed to chilling during the opera- 
tion, that the operation is not needlessly prolonged, and 
that as little blood as possible is lost during its perform- 
ance. The dtrtro-th.tr i air mattress may be used with ad- 
vantage, but care should be exercised in its employment, 
as serious burns have followed its use. The previous 
administration oi an ounce ol whiskey and the hypo- 
dermic injection of from 3^ to -^ ol a grain of sulphate 
of -trychnine. and the use 01 a small dose of morphine, in 
feeble and aged patients, will be followed by good results. 
A full de-se of quinine given an hour or two before the 
operation is also said to arrest the development of shock. 

Treatment. — The first indication in the treatment of 
shock is to establish reaction. The patient should be cov- 
ered with woollen blankets, the head should be kept low, 
and dry heat should be applied to the surface of the body 
by means of hot-water bags, hot bottles, or hot bricks ; 
these should be wrapped in towels to prevent them from 



INCISED WO UNI - 

comir^ :: ::Iv in contact with the surface: negle:: : 
this precaution 7 which is most important if the patient is 
unconscious, es burns which may be followed 

by extensive sloughing. If the patient can swallow, he 
should be given small quantities of whiskey or brandy, 
with 30 minim doses of aromatic spirit of ammonia, and, 
as absorption by the stomach is probably very slow in 
these cases, stimulants should be administered hyj 
mically : in our judgment, strychnine is the most valuable 
stimulant that can be employed. From - : - i - 
grain should, therefore, be injected, and the injection re- 
peated every hour or half-hour until several doses have 
been given. Caffeine citrate in doses _rs. ij may also 
be used with g res - sulphuric ether. 30 minims, 
may also be injected into the cellular tise - intervals, 
as well as digitalin or tincture of digitalis. 

- lock develops during an operation under ether anaes- 
. the use of ether hvpodennically is contraindi 
aulating enema of whiskey and warm water m 
employe*!. In cases of shock where there is pi 
sweating, the os _ . repeated 

s good salts. A large 

enema of warm saline solution may also be employed. As 
patients often complain of urgent thirst, it is well to let 
them take a little black ut not large quantities 

water; free indulgence in water does not s lench 

the thirst, and is apt to be foil _ Intra- 

venous injection of saline solution is likely I : most 

service when the - en preceded by tl 

of a large quantity of blood. Infusion of saline solution 
also has been employed with good results. 



DRESSING OF WOUNDS. 

Incised Wounds. — [These wounds present the condi- 

b' as : - >lc : r prompt healing, and after sterilizing 

the surrounding skin they should first be carefully irri- 

with saline solution or sterilized water, to remove 



266 MINOR SURGERY. 

any blood-clots or foreign bodies, or wiped with a ster- 
ilized gauze pledget ; and after any hemorrhage which 
is present is controlled by the use of ligatures, if the 
wound be an extensive or deep one, provision should be 
made for drainage by introducing a drainage-tube or a few 
strand- of sterilized catgut at the bottom of the wound, 
allowing the ends to project from its most dependent 
portion. Irrigation of the wound with a 1 : 2<X>0 or 
1 : 4000 bichloride solution may be employed if there is 
reason to suppose the wound has been infected before 
coming under treatment. In superficial incised wounds, 
after the hemorrhaee has been controlled, it is not usually 
found necessary to make provision for drainage. If the 
wound be a deep one, involving the muscles and deep 
fascia, buried sutures of catgut or silk should be applied 
to approximate the muscles and fascia : and if important 
nerves or tendons have been divided, their ends should be 
brought into apposition by sutures of catgut or sterilized 
silk : the superficial portions of the wound should next be 
brought together by the introduction of a number of 
interrupted sutures, catgut, silkworm-gut, silver wire, or 
silk being employed fur this purpose : the accurate appo- 
sition of the edges of wounds of this variety is secured by 
the introduction of a number of sutures placed closely 
together. 

After a wound of this variety has been closed, the sub- 
sequent dressing is accomplished by covering the surface 
of the wound with a number of layers of sterilized gauze 
and a pad of sterilized cotton, which are held in place bv a 
gauze bandage. Or a few layers of gauze, which have 
been soaked in a 1 : 2000 bichloride solution, may be 
applied to the wound, and over this is laid a pad of ster- 
ilized dry bichloride gauze of the same thickness, over- 
lapping the wet gauze by a few inches in all directions ; 
a few layers of bichloride cotton are next applied over 
the gauze dressings, and the whole dressing is secured in 
position by the application of a gauze bandage. Under 
this form of dressing prompt healing of incised wounds 
is the rule, and the wound need not be redressed for a 



LACERATED WOUNDS. 267 

week or ten days unless some indications exist for change 
of dressing at an earlier period. At the time of the first 
dressing the catgut drain or the drainage-tube is usually 
removed, and if adhesion of the edges of the wound is firm 
the sutures may also be removed. A sterilized or bichlo- 
ride gauze dressing is usually next applied, and allowed 
to remain for a few days longer. 

In superficial incised wounds involving only the skin 
and cellular tissue if limited in extent, after cleansing the 
wound and controlling the bleeding the edges should be 
approximated with sutures. The wound should then be 
covered with strips of sterilized gauze, over which is 
painted a mixture of: tr. benzoin, sj ; collodion, 3vij. 
This forms a firm antiseptic scab which need not be 
removed until the wound has healed. 

Lacerated Wounds. — These present edges which are 
torn and not sharply cut, and the vitality of the injured 
parts is often so seriously impaired that prompt union 
in this variety of wounds is not, as a rule, to be looked 
for. Wounds of this nature should first be irrigated with 
saline solution, sterilized water, or a 1 : 2000 bichloride 
solution, and blood-clots and foreign bodies removed. 
If the wounds be deep, drainage-tubes should be intro- 
duced ; on the other hand, if they be superficial, or if the 
edges are not closely approximated, provision for drainage 
may be omitted. The torn or irregular edges of the 
wound should next be brought into apposition at a few 
points, by the introduction of catgut or silkworm-gut 
sutures, applied not very closely together ; and if the 
edges are discolored and their vitality seems markedly 
impaired, it is better not to use sutures. If the edges of 
the wound are so much crushed that their vitality is 
destroyed, they may be trimmed away with scissors until 
a surface possessing a fair vitality is secured. The evil 
results arising from the introduction of sutures into this 
variety of wounds, with the idea of closely approximating 
their edges, are so common that the surgeon who dispenses 
with the use of sutures entirely errs upon the safe side. 
The use of manv sutures in wounds of this nature often 



268 MIS OR SURGERY. 

causes marked tension, which is frequently followed by 
impairment of the vitality of the injured tissues, and 
sloughing results. The wound should next be dressed 

with sterilized gauze and cotton, or a bichloride gauze 
dressing may be employed, and if it runs a favorable 
course it need not be redressed for a week or ten day- : 
the time required for repair of a wound of tin- nature is 

longer than that for an incised wound, and more frequent 
dressing may be required. 

In lacerated wounds of the extremities continuous irri- 
gation of the wound by a warm bichloride or carbolic solu- 
tion, applied as described, is often followed by the most 
satisfactory result- ; wounds produced by machinery and 
railway accident-, in which the vitality of the tissues is 
much impaired, are particularly suitable cases for this 
method of treatment, and here the same caution should 
be exercised as regards the introduction of sutures. 

Contused Wounds. — This variety of wounds possesses 
many characteristics in common with lacerated wounds : 
the edges are bruised and the injury of the subcutaneous 
tissue is often more extensive than the external wound 
would lead one to suspect. They are dressed in the same 
manner as lacerated wounds, and the same objection here 
exists to the use of sutures as in the latter class of 
injuries. 

1 Punctured Wounds.— These wounds are inflicted by 
sharp-pointed instruments, and it may happen that a por- 
tion of the vulnerating body remains in the wound, as 
is frequently the case in wounds produced by needles, 
splinters of wood, metal, or glass : another complication 
in this variety of wound is the injury of vessels, giving 
rise to concealed hemorrhage, or of nerves, resulting in 
neuritis or neuralgia. Simple punctured wounds should 
be irrigated with 1 : 2000 bichloride solution and covered 
by a sterilized or bichloride gauze dressing, and if no 
complication exists their healing is usually very rapid. 

A very serious form of punctured wounds arises from 
the impaling of a portion of the body by pieces of wood 
or metal, the part being transfixed or simply penetrated ; 



POISONED WOUNDS. 269 

the penetrating object may break off, leaving a portion of 
it in the wound, or may retain its position in the body, so 
that it is difficult to separate the body from it. This acci- 
dent usually results from persons falling upon sharp sticks, 
wooden or iron palings. 

AVhen a foreign body remains in the wound, as often 
happens in punctured wounds produced by needles and 
splinters, the punctured wound should be converted into 
an incised wound, and the body should be searched for 
and removed ; in doing this in the case of wounds of the 
extremities the operation is much facilitated by the em- 
ployment of Esmarch's bandage. The Rontgen or .r-rays 
may be employed with advantage in locating foreign 
bodies, such as pieces of glass or metal, in punctured 
wounds. After the removal of the foreign body the wound 
is treated as an incised wound, and an antiseptic dressing 
should be applied. When concealed hemorrhage occurs 
after a punctured wound, the wound should be laid open 
and the bleeding vessel searched for and ligated if pos- 
sible, and the wound should afterward be dressed as an 
incised wound. 

Poisoned Wounds. — These wounds are caused by the 
absorption, by means of a cut or abrasion in the skin, or 
by the sweat or sebaceous glands, of fluids from a dead 
body iu making dissections or post-mortem examinations, 
or in operating upon living subjects, and often result in 
serious consequences. Infection occurring from a living 
subject in operating is apt to give rise to a similar specific 
infection, or a mixed infection may result; whereas infec- 
tion occurring from dead bodies is usually caused by the 
bacteria of putrefaction, as infective micro-organisms 
retain their virulence for only a short time after death. 
Such wounds, as soon as possible after their reception, 
should be carefully washed out with a solution of bichlo- 
ride of mercury, 1 : 2000, and the surface touched with 
a 30-grain solution of chloride of zinc, and then dressed 
with an antiseptic dressing. If, however, this precaution 
is not taken, or the wound has escaped notice, and in a 
few hours becomes inflamed and painful, and evidences of 






270 MINOR SURGERY. 

lymphatic involvement show themselves, the wound should 
be opened and its surface should be thoroughly sponged with 
a 2 per cent, solution of formalin or with a 30-grain solution 
of chloride of zinc, and finally with a 1 : 2000 bichloride 
solution, and it should then be dressed with an antiseptic 
gauze dressing. Under this method of dressing, the poi- 
soned wound is often converted into a healthy one, even 
after the lymphatic involvement is well marked, and it 
usually heals promptly without further constitutional 
disturbance. 

Gunshot Wounds. — These wounds are produced by 
small shot, or fragments of shells, and are of the nature 
of contused and lacerated wounds, and the vulnerating 
body as well as portions of the clothing is often imbedded 
in the tissues. 

The modern small arms ball has much greater velocity 
than the leaden ball formerly employed ; it has great 
penetrating power, and is more apt to pass through the 
bones without comminuting them. Primary hemorrhage 
is also more common in injuries produced by this ball. 
Within a certain range it also possesses marked explosive 
action, producing great destruction of the tissues with 
which it comes in contact, which has been recently 
explained upon the theory of hydrodynamic pressure or 
vibratory action. The explosive effect of a small calibre 
ball depends upon its velocity, striking energy, area 
of impact, and the resistance to be overcome, so that 
the damage to the tissues in gunshot injuries is always 
greater at short range, and decreases with the increase 
of distance. Stevenson now maintains that the conclu- 
sions drawn from experiments upon dead animals and 
men are not borne out by what is observed when living 
men are wounded by small calibre projectiles. In dress- 
ing these wounds any foreign bodies, if they can be 
located, should be removed, and in the search for and 
removal of balls from the extremities the application of 
the Esmarch bandage will be found most useful. The 
arrays may also be satisfactorily employed in locating 
balls or fragments of metal in gunshot wounds. The 



CONTUSIONS OR BE VISES. 271 

wound should next be thoroughly washed out with a 
1 : 2000 bichloride solution, and an antiseptic dressing 
applied as in the case of other contused and lacerated 
wounds. 

Powder-burns. — These result from the explosion of gun- 
powder, and. in addition to the burning and laceration of 
the tissue-, are accompanied by the introduction of grains 
of unburnt powder into the skin, which, if not removed, 
leave permanent points of pigmentation. These wounds 
should first be washed with a 1 : 2000 bichloride solution, 
and upon the face, to avoid unsightly pigmentation of the 
skin, care should be taken to pick out the small masses 
of powder with a needle or the sharp point of a tenotomy 
knife. The surface should then be dressed witli antiseptic 
gauze or with lint spread with an ointment of boric acid 
or an ointment of aristol. consisting of half a drachm or 
a drachm of aristol to an ounce of vaseline, this dressing 
being covered by a few layers of gauze and cotton, held 
in place by a roller-bandage. 

In pigmented scars following powder-burns, the powder 
grain- may be removed by electrolysis. 

Contusions or Bruises. — These wound- differ from 
contused wound- in the fact that the skin is not broken, 
although in -pite of this tact there may exist very exten- 
sive laceration of the subcutaneous ti--ues. accompanied 
by more or less extravasation of blood from the injured 
ve--el-. When not sufficiently severe to require operative 
treatment, they should be dressed by applying over them 
several layer- of lint saturated with lead-water and lauda- 
num, and over this dressing is placed a layer of waxed 
paper or rubber-tissue, and the dressing is secured by a 
roller-bandage. A solution which I find most satisfac- 
tory in the dressing of contusions is as follows : ammonii 
chloridi. grs. xx ; tr. opii et alcoholis. aa fgj ; aqu?e, f=ij. 
Several layer- of lint saturated with this solution are laid 
over the contused tissue-, and are covered with waxed 
paper, oiled silk, or rubber-tissue. 

Extensive collections of blood following contusions often 
remain in the tissues for some time, but usually are ab- 



272 MINOR SURGERY. 

sorbed. If this result does not follow, or an abscess forms, 
the blood or pus should be removed by aspiration or by 
incision with full antiseptic precautions. 

Brush-burn. — This is a form of contused and lacerated 
wound which is produced by violent friction applied to the 
surface of the body, and is often caused by coming in 
contact with rapidly revolving wheels or the belting of 
machinery, or by the body being rapidly propelled over an 
uneven surface, or by a rope being rapidly drawn through 
the closed hands. The injury may vary from a superficial 
abrasion to absolute destruction of the skin. The sur- 
face of the brush-burn should be cleansed by a stream of 
normal salt solution, sterilized water, or 1 : 2000 bichloride 
solution, and then dressed with a powder of acetanilid and 
boric acid, equal parts, and a sterilized gauze dressing ap- 
plied ; if suppuration occurs, a moist bichloride or acetate 
of aluminum dressing or boric acid ointment should be 
applied. 

Burns and Scalds. — The dressings employed in the 
treatment of burns and scalds are similar, as the injury to 
the tissues is practically the same in both classes of injuries. 
Superficial burns or scalds, in which the effect of the heat 
has extended only to the superficial layer of the skin, may 
be treated by the application of lint saturated with a solu- 
tion of carbo7iate of sodium, a drachm to an ounce of water ; 
this dressing rapidly relieves the pain, and is a satisfactory 
application in this variety of burns and scalds. In cases 
in which the effects of heat have extended to the deeper 
tissues, the affected surface may be dressed with Carron oil, 
which is prepared by rubbing together lime-water and lin- 
seed oil until a thick, creamy paste results ; lint is saturated 
with this mixture and laid over the surface of the burn or 
scald. This dressing is a comfortable one to the patient, 
but possesses no antiseptic qualities and soon becomes 
offensive, and for this reason requires frequent renewal. 

White-lead Dressing. — This application, which con- 
sists of white lead (^viij), powdered acacia (3ij), sodium 
bicarbonate (3J), and linseed oil (a sufficient quantity to 



BURNS AND SCALDS. 273 

make a mixture of the consistency of thick cream), is ex- 
tensively used in the coal regions of Pennsylvania, where 
severe burns are very frequent. It is spread upon lint or 
gauze and applied to the burned surfaces ; it does not re- 
quire frequent renewal, and repair of the injured surfaces 
is rapid under its use. 

Picric Acid Dressing. — Picric acid solution has re- 
cently been very extensively used in the treatment of 
burns and scalds. After the surface has been cleaned 
and blebs have been opened, strips of sterilized lint or 
gauze are soaked in the solution and applied to the sur- 
face and covered with a layer of dry absorbent cotton, 
and the dressing is held in place by a bandage. The 
dressing soon dries and may be left in place for several 
days, when it is reapplied in the same manner. This 
application relieves pain and seems to diminish sup- 
puration and leaves a healthy scar. The solution em- 
ployed is as follows : Picric acid, gr. lxxv ; alcohol, siiss ; 
aquae dest., Oij. 

The disadvantage met with in the antiseptic method of 
dressing burns and scalds is the fact that the raw surface 
presented offers most favorable conditions for absorption 
of the antiseptic substances employed in the dressings, 
and for this reason the use of bichloride of mercury, car- 
bolic acid, and iodoform is not to be recommended in 
burns or scalds involving a large extent of surface, on 
account of the toxic symptoms which may result from 
their absorption. 

In Germany the treatment of extensive burns by con- 
tinuous immersion of the patient in a warm bath has been 
followed by good results. 

Asa recent burn or scald, by reason of the heat employed 
in its production, is practically an aseptic wound, a simple 
sterilized dressing may be employed. It may be dressed 
by covering it with a number of layers of sterilized gauze 
and cotton, or with powdered boric acid, aristol, or acetan- 
ilid, and placing over this a number of layers of sterilized 
cotton, holding the dressings in position by a bandage. 

18 



27-4 MINOR SURGERY. 

If. however, a full antiseptic dressing is employed, the 
injured surface should first be irrigated with a 1 : 4 
bichloride solution, and then covered with protective or 

rubber-tissue which has been sterilized, and over this a 
dressing of bichloride or sterilized gauze and bichloride 
cotton should be applied. If this dressing is employed, 
the patient should be carefully watched for the develop- 
ment of toxic symptoms. 

When blebs are present upon the surface of the burn or 
scald, they should be opened to allow the serum to escape. 
If suppuration occurs, or the tissues become necrosed by 
reason oi the severity of the injury, the surface of the burn 
may be irrigated with normal salt solution or a 1 : 4000 
bichloride solution, and the same dressing should then be 
applied. 

Ulcers resulting from separation of the dead tissues 
should be touched with a solution of nitrate of silver. 5 
grains to the ounce of water, and dressed with lint spread 
with an ointment of boric acid, aristol. or ichthyol. In 
the dressing of extensive burns or scalds of the neck, race, 
and region of the joints, the possibility of serious defor- 
mity from contraction of the tissues in healing should not 
be lost sight oi. and position, splints, and bandages should 
be employed to prevent, as far as possible, this complica- 
tion. 

Injuries from Electricity. — Since the extensive intro- 
duction of electricity in the art-, injuries from contact with 
heavily charged wires are of frequent occurrence. If the 
current be a strong one. death may be instantaneous, or 
the patient may be knocked down, become unconscious, 
and present severe burns at the point of contact, then 
regain ns :iousnes-. and subsequently suffer from numb- 
ness in the extremities traumatic nenroses, and in rare 
ca-es true paralysis. If the skin be dry at the time the 
current is received, there will be more bnrnincf. less pene- 
tration and less shock, and less danger of death. The 
burns are not painful, but are apt to be followed by exten- 
sive sloughing. Alternating currents are more dangerous 
than continuous current- : a continuous current of one 






IXJURIES FROM ELECTRICITY. 275 

thousand volts is not apt to be followed by serious conse- 
quences, whereas an alternating current of the same strength 
is likely to produce death. 

Death from exposure to strong alternating currents is 
considered by Hedley to be caused by destruction of the 
tissues or by arrest of respiration producing asphyxia. 
Exposure to a strong electric current may produce burns 
or ecchymoses, and occasionally wounds ; the latter bleed 
freely and are apt to slough. A burn from electricity 
presents a dry blackened surface and is surrounded by an 
area of pale skin. They are not as painful as ordinary 
burns, but healing in electric burns is usually slow. In- 
flammation and suppuration of the tissues usually develop 
in a few days, and are often followed by the development 
of an extensive area of moist gangrene, a small burn 
being followed by extensive and deep destruction of the 
surrounding tissues. 

Treatment. — The treatment of a person who has been 
exposed to a strong electric current, even if apparently 
lifeless, consists in practising artificial respiration, Laborde's 
or Silvesters method being employed ; also friction to the 
surface of the body and enemata of hot saline solution ; in 
some cases venesection has been employed with advantage. 
Hedlev records a case of apparent death in a man who 
received an alternating current of four thousand five 
hundred volts short-circuited through his body for many 
minutes, who showed no signs of life for thirty minutes. 
In this case, after the employment of Laborde's method 
of artificial respiration for some time, normal respiratory 
action was restored, and the patient recovered. Artificial 
respiration should be practised in all cases, and should be 
continued until it is certain that the patient is dead. At 
the same time strychnine should be used hypodermically. 

The burns should be treated by the application of anti- 
septic dressings, but these often fail to arrest the sloughing. 
DaCosta recommends in the early stage of these burns 
the use of fomentations of hot saline solution, which facili- 
tates separation of the sloughs, and in the subsequent 
dressing of the wounds peroxide of hydrogen followed by 



276 MINOR SURGERY. 

irrigation with saline solution. After the sloughs have 
separated, dry sterilized dressings should be employed. 

Lightning- stroke. — In this form of electric injury a 
person may be struck directly or may be shocked by an 
induced current, the lightning having struck some object 
near at hand. The results of lightning-stroke upon the 
body differ according as the electrical or the burning 
action predominates. There may be present severe burns or 
extensive lacerations, involving the muscles, bloodvessels, 
and bones ; or sudden death may result from paralysis of 
the respiration and circulation. Upon regaining conscious- 
ness, the patient may complain of disturbance of vision, 
and may suffer from paralysis of the nerves of motion or 
sensation ; paralysis of the lower limbs is said to be more 
common than that of the upper limbs. 

Treatment. — The treatment of the stage of shock follow- 
ing lightning-stroke consists in the application of external 
heat, the employment of artificial respiration, and the 
administration of stimulants. If burns exist upon the 
surface of the body, they should be treated like burns 
arising from artificial currents. If paralysis persists for 
some time after recovery from the immediate effects of the 
shock, the use of galvanism and the administration of 
strychnine may be followed by good results. 

X-Ray Burns. — A peculiar lesion of the skin and sub- 
jacent tissues, following prolonged exposure to the .r-ravs, 
resulting in ulceration of the skin and loss of the nails 
and hair in the damaged area, is described as an rr-ray 
burn. This lesion differs from an ordinary burn in that 
it may not appear for several days or weeks after the 
exposure, and that the inflammatory or gangrenous process 
arises in the tissues and finally involves the skin. These 
lesions are very painful and slow in healing; and if an 
extensive surface be involved, they may result in serious 
consequences : amputation of the limb has been demanded 
by reason of a burn of this nature. The lesion is prob- 
ably due to trophic changes. 

Treatment. — The dressings employed in ordinary burns 
have not proved satisfactory in these injuries. Dry steril- 



BEDSORES. 277 

ized dressings may be employed, and skin-grafting when 
the ulcerated surface is extensive may be of service. 
When a small area only is involved, and healing fails 
to occur, Powell recommends excision of the ulcerated 
tissues. 

Bedsores. — These sores usually occur over the sacrum 
or hips in patients who are confined to bed for a consider- 
able time, as the result of long-continued pressure, or in 
cases where the vital powers are depressed by ady- 
namic diseases, and are also a frequent and troublesome 
complication in spinal injuries, in which cases they result 
from trophic disturbances. Their formation may be pre- 
vented in many cases by the use of air-cushions or of a 
water mattress, and by keeping the parts exposed to press- 
ure scrupulously clean and frequently bathing them with 
stimulating lotions, such as alcohol, olive oil and alcohol 
(equal parts), or soap liniment. The parts should also be 
protected from pressure by the application of adhesive 
plaster, or, still better, soap plaster spread upon chamois 
skin. When a bedsore has actually formed — and in many 
cases its formation is very rapid and the slough will be 
found to involve a large surface of the skin over the sac- 
rum, and to extend down to the bone — we have present a 
very serious complication, and one which requires most 
careful treatment. 

The dressing of a bedsore before separation of the 
slough consists in relieving the part from pressure by the 
use of an air-cushion placed under the buttocks, and the 
application of a moist antiseptic dressing until the slough 
has separated. When the slough has become detached, the 
ulcer remaining should be well irrigated with a 1 : 2000 
bichloride solution, and the granulations touched with 
a 5-grain solution of nitrate of silver ; and aristol, or 
boric acid ointment spread upon lint, should be applied 
to the surface of the ulcer, and a piece of soap plaster a 
little larger than the ulcer should be placed over this dress- 
ing and held in place by broad strips of adhesive plaster. 
This dressing should be renewed every day or every other 
day, and means should be adopted to protect the parts 



278 MIS OR SURGERY. 

from farther pressure, and the constitutional condition of 
the patient should be improved by the administration of a 
nutritious diet, tonics, and stimulants. The application 
of the galvanic current has been employed to promote 
healing of the ulcer in obstinate cases. 

Sprains. — Sprains of the joints from twists or other 
external violence resulting in the stretching or laceration of 
the ligaments are injuries which require careful dressing. 

Sprains may be first treated by the application of cold- 
water or hot-water dressings for a few hours, or by the 
application of lead-water and laudanum, the joint being 
kept at rest by the use of a splint or by confining the 
patient in the recumbent posture in the case of sprains of 
the joints of the lower extremities. 

After a few days' use of the lead-water and laudanum 
dressing the swelling usually subsides, and the joint may 
be fixed by the application of a moulded soap-plaster splint 
or felt splint held in place by a firmly applied roller-band- 
age, which should be worn for a week or ten days ; in 
ordinary cases after this time the splint may be removed 
and the patient should be encouraged to use the joint. In 
cases of severe sprains, on the other hand, the pain and 
swelling persist for some time, and here the fixation of the 
joint by a plaster-of-Paris bandage will be found useful 
for a few weeks. 

In the chronic stage of a sprain, after all dressings have 
been removed, the methodical use of massage is often most 
beneficial ; and after the parts have been thoroughly man- 
ipulated a flannel bandage should be applied, which, by its 
elasticity, gives a certain amount of support to the parts. 

Strapping. — The treatment of sprains which I have found 
the most satisfactory, both in the acute and chronic stage, 
consists in the use of strapping. Strips of adhesive or 
rubber adhesive plaster one and a half inches in width are 
applied around the joint, and are made to extend some 
distance above and below it ; a gauze bandage is next 
applied over the straps, and the patient is allowed to u>e 
the part as soon as he can do so without discomfort (see 
page 176). 



SPRAIN-FRACTURE. 279 

Sprain-fracture. — Under this name Mr. Callender has 
described an injury which consists in the separation of a 
ligament or tendon from its point of insertion into a bone, 
with the detachment of a thin shell of the bone ; this 
injury is apt to occur about the ankle-joint, knee-joint, 
elbow-joint, and wrist-joint, and the treatment is the 
same as that of an ordinary fracture in the same locality. 
This injury is probably much more common than is gen- 
erally supposed in connection with sprains of the joints, 
and is, I think, in many cases the cause of tardy restora- 
tion of the function of sprained joints, this injury being 
overlooked, simply being treated as a sprain, and the 
patient being encouraged to use the part before union of 
the bone has been accomplished. 

Strains of Muscles and Fascia. — These vary in sever- 
ity from simple stretching of the fibres to absolute rupt- 
ure, and should be treated by putting the parts at rest and 
by the application of pressure by means of adhesive straps 
or of a bandage ; in strains of the muscles and fascia of the 
back the use of broad strips of adhesive plaster, applied 
as in cases of fracture of the ribs, will be found most sat- 
isfactory. In the treatment of the later stages of these 
injuries the employment of massage will often be followed 
by good results. 



PART III. 
ASEPSIS AND ANTISEPSIS 



SURGICAL BACTERIOLOGY. 

Bacteria (Schizomycetes). — These are minute cellular 
organisms of microscopic size, classified as belonging to 
the vegetable kingdom, among the fungi. They play an 
active part in the causation of the processes of fermenta- 
tion and putrefaction, and are the causal agents of many 
varieties of diseases. The word germ is often used as 
synonymous with bacterium in speaking of the organisms 
that cause disease, but we must remember that certain 
pathogenic germs, as the hcematozoon malarias, the amoeba 
coli, and the coccidia, are members of the animal king- 
dom and are not bacteria. 

Bacteria may be divided into the lower and the higher 
bacteria. The lower forms are always unicellular, although 
in the process of growth cells may remain attached to 
each other ; while the higher forms are filamentous, often 
branched, are made up of numbers of simple cells joined 
together, and the cells sometimes show a tendency to 
specialization. To this class belong the organism which 
causes actinomycosis, the aetinomyees bovis seu hominis, 
and also the streptothrix madurce, the organism of Madura 
foot or mycetoma. The lower bacteria, with which we are 
mainly concerned, are unicellular and exceedingly minute, 
the round forms measuring not more than 1 micromilli- 
metre ( 25000 inch) in diameter, and, therefore, only 
capable of investigation under the highest powers of the 



282 ASEPSIS AND ANTISEPSIS. 

microscope. When unstained they appear to be homo- 
geneous, but by staining they can be seen to possess a cell- 
wall or limiting membrane, not always well defined, called 
the ectoderm, enclosing the protoplasmic contents or enclo- 
derm, which contains no nucleus. The cell- wall is probably 
of a gelatinous nature, and when it is well defined the bac- 
teria are said to be capsulated. In the protoplasm of the 
cell-body certain bodies, metachromic granules, are some- 
times seen by staining, as well as other round or oval 
unstained spaces, which, when situated at the ends of a 
bacillus, are known as polar granules. Both of these are 
probably either the results of degenerative changes, or are 
artificially produced in drying. 

Certain bacteria produce coloring-matters — red, yellow, 
and blue — many of which are allied to the lipochromes, 
a class of coloring-matters found in certain animal and 
vegetable organisms. 

Unicellular bacteria are classified according to their 
shape into cocci, or round cells, bacilli, or rod-shaped 
cells, and spirilla, which are cylindrical cells of curved or 
spiral outline. Motility in those bacteria which possess it 
is due to the presence of cilia or flagella. The ordinary 
mode of growth of bacteria is by division or splitting. 
Under circumstances unfavorable to growth they may 
also produce spores, but not as a means of multiplication, 
as one bacterium usually produces but one spore. 

Spores. — These may be of endogenous or arthrogenous 
origin. Endogenous spores arise especially in the bacilli. 
They appear in the protoplasm of the cell as granules, 
which develop into round, oval, or short rod-shaped 
bodies, the remaining portion of the bacterium either 
persisting for a time or disappearing very soon. Arthro- 
genous spores appear to be cocci which have swollen, 
become more refractive, and are more resistant to unfav- 
orable surroundings than the original coccus. Spores are 
highly refractive, and consist of a protoplasmic body with 
a dense surrounding membrane. They are very resistant 
to unfavorable surroundings, and are much more difficult 
to destroy by heat, chemical reagents, or drying, than are 



SURGICAL BACTERIOLOGY. 283 

adult bacteria. When placed under circumstances favor- 
able to their growth, the capsule splits, and a little bud 
appears and develops into an adult bacterium. 

The ordinary method of multiplication of bacteria is by 
division or fission, one individual dividing into two, and 
these again into two more, the process sometimes taking 
place with great rapidity. The new cells may remain 
attached or separate, according to the nature of their 
limiting membrane. In the case of cocci, when forming 
pairs, they are called diplococci. They may also be tetra- 
genous, or form chains, as in the streptococci and strepto- 
bacilli ; or bunches, as in the case of the staphylococci. 
A zooglea mass is formed by the cohesion of a large num- 
ber of bacteria, where, owing to the gelatinous nature of 
their envelopes, they adhere to each other and appear to 
be imbedded in jelly. 

Bacteria are found widely distributed in the air, the 
water, the earth, and wherever there is organic substance 
from which they can obtain their nutrition. They live 
by breaking up into simpler forms the complex organic 
compounds on which they are dependent for their carbon 
and nitrogen, being unable to extract the same from inor- 
ganic material. They also require moisture, being de- 
stroyed in time by drying. Those which require oxygen 
are called aerobic, while those which only grow when it is 
excluded are called anaerobic. Facultative aerobic and 
facultative anaerobic are terms used to designate those 
bacteria which can grow in its presence or absence ; the 
first, however, growing best with and the latter best with- 
out it. Another division of bacteria is into saprophytic, 
or those living on dead organic matter, and parasitic, or 
those depending on living organisms, the latter embracing 
the pathogenic bacteria. The boundary line between these 
two classes is not well defined, however. A certain 
amount of heat is necessary to bacterial existence, the 
pathogenic germs growing best at the body temperature ; 
they are destroyed by high temperatures, most of the 
pathogenic bacteria being killed between 122° and 140° 
F. (50° and 60° C). The spores are, as a rule, much 



284 ASEPSIS AND AXTISEPSIS. 

more resistant to heat. Low temperatures tend to inhibit 
the growth of bacteria rather than to destroy their life. 
Direct sunlight also has an injurious action upon them. 

Cultivation. — Bacteria are studied outside of the body 
by growing them on culture-media, which may be liquid 
or solid, proteid or carbohydrate-containing material. The 
media are sterilized and kept in tubes or dishes (Petri's 
dishes). A little of the culture or material to be studied is 
transferred to the culture-medium by a sterilized platinum 
wire (called an ose), and spread on the surface of the solid 
medium (stroke-culture), or plunged into it (stab-culture), or 
mixed with the fluid medium. The tubes or plates are 
then placed in an oven heated to the required temperature. 
The germs form colonies of characteristic size, shape, and 
coloring, and the different species may thus be isolated and 
studied. The liquid media include bouillon, peptone solu- 
tion, and extracts of vegetable substances, as potato. Solid 
media include mixtures of beef-extracts with gelatin or 
agar-agar, coagulated blood-serum, and slices of potato or 
other vegetables. 

Inoculation. — The action of bacteria and their toxins 
is studied experimentally by the injection of cultures, or 
of the body fluids or the juice of bacterially infected tis- 
sues into some of the lower animals. The animals usually 
employed are the guinea-pig, rabbit, mouse, rat, and 
pigeon. Injections are made with a sterile hvpodermic 
syringe under the skin, into the peritoneal cavity, intra- 
venously, and into the anterior chamber of the eye, or the 
skin may merely be scarified. The animal is carefully 
watched afterward, its symptoms noted, and when dead of 
the disease, or killed, cultures are made from the organs 
and the tissue-changes studied. 

Staining. — In order to detect bacteria in the tissues, or 
to study and differentiate them from each other, it is neces- 
sary to stain them, and this is accomplished by the use of 
dilute aqueous or alcoholic solutions of the aniline dyes, 
counter-staining the tissues to make their detection easier. 
Bacteria differ widely in the facility with which they take 
the stains, some staining readily, while others require the 






SURGICAL BACTERIOLOGY. 285 

action of heat or of a mordant ; and they differ also in the 
tenacity with which they retain the stains in the presence 
of various reagents, as alcohol and the mineral acids. We 
are thus able to separate different bacteria by the use of 
special methods of staining and decolorizing. Fer exam- 
ple, the gonococcus, the bacillus coli communis, and the 
typhoid bacillus are decolorized by the use of Gram's 
method ; while the bacilli of anthrax, tuberculosis, diph- 
theria, and tetanus are stained by it. The aniline stains 
most frequently employed are methylene-blue, gentian- 
violet, thionin, fuchsin, dahlia, and vesuvin. 

Koch's Law. — To prove that a certain bacterium is the 
cause of a disease, the following rules have been laid down 
by Koch : The bacterium must first be found in the dis- 
eased person or animal. It must be cultivated outside of 
the body. When inoculated in pure culture in a healthy 
animal it must produce the original disease. From the 
body of the animal the original microbe mast be capable 
of again being isolated. 

Entrance of Bacteria into the Tissues. — Bacteria 
may gain entrance into the tissues of the body through 
the skin or mucous membrane, or by means of wounds 
or other primary surgical affections. The direct entrance 
of bacteria into the blood-current sometimes occurs, but is 
rare. When entrance occurs through apparently intact 
skin it is likely that small lesions of the skin are present 
and have been overlooked. The mucous membranes are 
less resistant to the entrance of bacteria. Fresh wounds 
present conditions most favorable for the entrance of bac- 
teria into the system. 

The relation of insects to the spread of infectious agents 
has recently attracted much attention. It has been shown 
that insects not only transport disease-producing micro- 
organisms, but may also be the agents of inoculation of 
pathogenic micro-organisms. 

It has been shown that the location of entrance of bac- 
teria bears a more or less direct relation to the severity of 
the infection. It has been demonstrated in animals that 
direct inoculation into the peritoneal cavity and general 



286 ASEPSTS AND ANTISEPSIS. 

vascular system are followed by much more severe symp- 
toms than subcutaneous inoculations. 

Schemmelbusch has shown that the absorption of bac- 
teria in fresh wounds by lymph and blood-vessels is very 
rapid, and that the absorption is markedly interfered with 
by the presence of a blood-clot. The surface of a healthy 
granulating wound also offers great resistance to the en- 
trance of bacteria. 

Intoxication and Infection. — Bacteria usually gain 
entrance into the body through some break in the conti- 
nuity of the skin or mucous membrane, especially the latter, 
owing to its being easier of penetration. They often enter 
through an open wound. Favoring elements are a weak- 
ened or diseased state of health of the individual, or an 
unusual virulence of the germ. If the germs remain 
localized, and only their products are absorbed, the proc- 
ess is spoken of as intoxication. If the germs themselves 
enter the circulation, we have infection, although the term 
infection is used also by surgeons to denote the presence 
of bacteria in a wound, without necessarily or even usually 
implying their presence in the circulation. If the germ 
be pyogenic — that is, one that excites suppuration — the 
symptoms produced by the absorption of its products con- 
stitute saproemia ; if the germ enters the circulation, we 
have septicaemia ; and if it finds lodgement in the tissues 
or organs and gives rise to secondary abscesses, we have 
pyaemia. 

Elimination. — Bacteria are eliminated by the kidneys, 
the intestine, the salivary glands, in the bile and milk, and 
probably also by the sweat-glands. They frequently cause 
lesions in the eliminating organ. 

Pathogenic Action. — The pathogenic action of bacteria 
is due to the formation of certain poisonous products 
secreted by them, or produced by their action upon the 
tissues. From the bacteria themselves, by their degenera- 
tion, we have also formed the proteins. The bacteria by 
their secretion produce the ferments, and, perhaps, the toxins; 
and by their action upon the tissues we have produced the 
ptomaines, amines, peptones 3 albumoses, fatty acids, etc. 



IMMUNITY. 287 

Toxins. — The toxins are produced by the pathogenic 
bacteria. They are poisonous when injected, even in very 
minute doses, acting after a period of incubation, and are 
looked upon by many observers as being of the nature of 
ferments. Others have classified them as toxalbumins or 
toxalbumoses. The different pathogenic bacteria elaborate 
their own specific toxins. Some of them have a local as 
well as a general action, producing inflammation, necrosis, 
etc., when injected into living animals. 

Resistance of the Tissues to Bacteria. — That the 
introduction of bacteria into the body is not always fol- 
lowed by the development of disease is due to a number 
of circumstances, one of the most important being the 
resistance offered by the tissues. Certain of the leuco- 
cytes have what is known as a phagocytic action — that 
is, the power to take into themselves and destroy by 
intracellular action the invading germs. The leucocytes 
appear to be attracted to the germs by a power residing 
in the bacteria, known as positive chemotaxis, their migra- 
tion being accompanied by the nutritive changes consti- 
tuting the process of inflammation, and in the case of 
pyogenic germs of suppuration. Inflammation seems to 
be a limiting and protecting process. The bacteria if very 
virulent may overcome the leucocytes, or repel them by 
the production of toxins, which are negatively chemotactic 
— that is, they repel the leucocytes and interfere with their 
phagocytic action, and we have in consequence a general 
invasion of the organism by the bacteria, often without 
any local inflammation. In addition to the phagocytic 
action of the leucocytes, the blood and fluids of the body 
have a certain germicidal pow T er, said to be due to the 
presence of albuminous bodies — alexins. The presence in 
a wound of a foreign body favors the growth of bacteria, 
as does, to a certain extent, the presence of blood-clot or 
other material which may act as a culture-medium for the 
germs. 

Immunity. — This consists in the freedom from liability 
to a disease, and may be natural or acquired. In natural 
immunity the person Or animal is immune from birth ; 



288 ASEPSIS AND ANTISEPSIS. 

while acquired immunity may be the result of a previous 
attack of the disease or may be produced artificially. As 
examples of natural immunity we have that shown by the 
lower animals to syphilis and leprosy, and of man to cer- 
tain diseases of the lower animals. One attack of small- 
pox, scarlet fever, or typhoid fever confers an acquired 
immunity on the patient which is usually permanent; 
while an attack of pneumonia, influenza, or diphtheria is 
followed by a period of temporary immunity. Immunity 
may also be absolute or relative ; the first being rare, the 
latter common, being overcome by unusual conditions. 
Artificial immunity is active or passive. Active immunity 
is obtained by the injection into animals of increasing 
doses of a pathogenic organism, or of its toxins, the dose 
being gradually increased until a high degree of immunity 
is obtained. This method is preventive of future attacks, 
but owing to its slowness is not useful against an existing 
disease. Passive immunity, which is less lasting than 
active immunity, is conferred by the injection into an 
animal of the serum of an animal that has been highly 
immunized by the previous method. The serum will 
destroy existing toxins and organisms, and confer tem- 
porary immunity against further infection. 

Antitoxin. — The mechanism of the production of im- 
munity is largely, if not altogether, dependent upon the 
formation, by the reaction of the tissues to the toxins, of 
an albuminous body known as antitoxin. To the presence 
of this substance in the serum of an actively immunized 
animal is due its curative power when injected into an 
animal suffering from the same disease. The antitoxin of 
diphtheria has been widely employed of late years with 
beneficial results, and the investigations now being carried 
on in tetanus, hydrophobia, anthrax, and other diseases, 
afford foundation for the hope that similar good results 
may be obtained with their antitoxins. A distinction is 
made between antitoxic serum and antimicrobic serum : 
the former being produced by the injection of tox- 
ins, and the latter by the injection of living bacteria. 
The antimicrobic serums tend to the destruction or 



BACTERIA OF SUPPURATION. 289 

paralysis of the micro-organisms, but not necessarily of 
their toxins. 

Varieties of Bacteria. 

The bacteria of importance surgically are those giving 
rise to ordinary suppuration, the gonococcus, the tubercle 
bacillus, the bacillus of malignant oedema, of glanders, of 
anthrax, of tetanus, of infectious emphysema, and the 
organisms causing actinomycosis and mycetoma. 

Bacteria of Suppuration. — A large number of bac- 
teria are capable of giving rise to suppurative inflam- 
mation, but the most important are the staphylococcus, 
especially the staphylococcus pyogenes aureus, and the 
streptococcus pyogenes or streptococcus erysipelatis, they 

Fig. 225. Fig. 226. 



Staphylococcus pyogenes aureus. Streptococcus pyogenes. 

being identical. Besides these, as rarer causes, we have 
the bacillus pyoevaneus, the bacillus ccli communis, the 
typhoid bacillus, the gonococcus, the diplococcus pneumo- 
niae and the bacillus pneumoniae (Friedlander). 

Staphylococcus Pyogenes Aureus. — This bacillus, which 
causes 80 per cent, of suppurative inflammations, and is 
almost always the cause of osteomyelitis, grows in clusters 
(Fig. 225), can be cultivated on ordinary media, but best 
on agar, and forms small round colonies, at first whitish, 
later of an orange-yellow color. It is found in health on 
the skin, in the pharynx, and in the external secretions. 

The staphylococcus pyogenes albus, or epidermis albus, as 

19 



290 ASEPSIS AND ANTISEPSIS. 

it is called, from being found in the epiderm, is less viru- 
lent than the preceding, and forms white colonies. It not 
infrequently is the cause of stitch abscesses. 

Streptococcus Pyogenes. —This is a small round organ- 
ism which forms chains (Fig. 226). It is found occasion- 
ally on mucous surfaces in health, and causes dangerous 
phlegmonous inflammations. It also causes erysipelas, 
being identical Avith the streptococcus erysipelatis. 

Bacillus Coli Communis. — This is a rod-shaped bacillus, 
and may be long and slender or short and rounded. It 
strongly resembles the typhoid bacillus. It is provided 
with flagella. It is found in the intestines in health, and 
seems to acquire virulent properties from inflammation 
or strangulation of the bowel, giving rise to appendicitis 
and peritonitis by migration through the diseased wall of 
the bowel or by escape through a rupture ; it may also be 
the cause of cystitis, pyelitis, pyelo- 
Fig. 22/. nephritis, and occasionally of local- 

ized abscesses. 

Gonococcus. — This, the germ of 

gonorrhoea, is a kidney -shaped coccus, 

arranged in pairs, with the concave 

edges toward each other ; the diplo- 

cocci usually inhabit the pus-cells, 

Gonococcus. (After bumm.) but are occasionally free (Fig. 227). 

Besides specific urethritis., it causes 

salpingitis, oophoritis, arthritis, endocarditis, conjunctivitis, 

proctitis, and other lesions. 

Tubercle Bacillus. — This, the cause of tuberculosis, is a 
rod-shaped bacillus, sometimes slightly curved, 1.5 to 3.5 
micromillimetres in length and 0.2 to 0.5 micromillimetre 
thick. It is not motile, and occurs singly, in pairs, and 
in groups ; spore-production has not as yet been demon- 
strated (Fig. 228). Inoculation may be directly through 
a wound, or by inhalation, ingestion, or placental trans- 
mission, the last being rare. It may infect any organ of 
the body. It causes tuberculosis in many of the lower 
animals, cattle being especially liable to its infection. 
Bacillus Mallei. — Glanders is caused bv this bacillus, 




BACTERIA OF SUPPURATION. 



291 



which resembles the tubercle bacillus, but is shorter and 
thicker (Fig. 229). Infection of the mucous membranes 
of the respiratory tract and through the skin is not un- 



Fig. 228. 



Fig. 229. 







Tubercle bacilli. 



Bacillus mallei 



^<c*^ 



common in men who are exposed to infection from 
horses. 

Bacillus Anthracis. — This, the cause of anthrax, is a 
very large, straight bacillus, usually from 5 to 20 micro- 
millimetres in length, sometime.-, however, attaining a 
length of 50 micromillimetres. It forms long chain- and 



Fig. 230. 




Threads of bacillus anthracis con- 
taining spores. 



\ 



Fig. 231. 



\R~ \ 72* 



b *■* 



Tetanus bacillus. 



produces spores, which are very resistant (Fig. 230). 
Infection in man usually arises from handling infected 
skins and hides, and causes a local inflammation, with 



292 ASEPSIS AND ANTISEPSIS. 

general septicaemia. Infection may also take place through 
the lungs or through the gastro-intestinal tract. 

Bacillus of Tetanus. — This is a rod-shaped organism 
which, owing to the formation of a spore at one end which 
distends it, is often of a drumstick shape (Fig. 231). It 
is anaerobic, being found especially in garden-earth, in 
the excrement of animals, and around stables. Infection 
follows w T ounds, especially punctured wounds by nails or 
splinters, which are liable to be contaminated from the 
earth ; infection is also quite common in puerperal women 
and in the newborn. Suppuration in a wound favors 
its development. The bacterium apparently remains 
localized, producing its characteristic symptoms by the 
action of very powerful toxins, of which two, tetanin and 
tetanotoxin, have been isolated. An antitoxin has been 
isolated from immunized animals, and good results have 
been reported from its administration in individuals suffer- 
ing from tetanus, but it has often proved disappointing. 
Bacillus of Malignant (Edema. — This resembles the 
anthrax bacillus in appearance, being 
Fig. 232. more slender, however, and, like it, has 

* K ^ a tendency to form chains. It is mo- 

& ^ ^ ^ tile, being provided with flagella, is 
& ' ** V^ anaerobic, and forms spores (Fig. 232). 
& ^ ^> It occurs in the soil, in dust, and in 
"— * ^ the contents of the intestines of lower 

*? -**■ ^ <=» animals. In the lower animals it is the 
*? ^? «z*n^ cause of the disease known as malig- 
** ^ nant oedema, which is associated with 

^dema.fpo^elt^ suppuration and necrosis of the sub- 
cutaneous tissues, emphysema, and gan- 
grene. In man it has been found in certain cases of 
rapidly spreading traumatic gangrene and gangrenous 
emphysema, arising in connection with compound fract- 
ures and other deep punctured wounds. 

Bacillus Aerogenes Capsulatus. — This organism is from 
3 to 6 micromillimetres in length, and may be found 
singly, clumped, or in chains. It is non-motile, anaerobic, 
and does not form spores. It finds entrance into the body 



BACTERIA OF SUPPURATION. 293 

through a wound or ulceration, external or internal, and 
its effects resemble somewhat those produced by the 
bacillus of malignant oedema, viz., necrosis, gangrene, and 
the production of gas, which in this case is found in any 
or all of the tissues and organs and in the blood, in the 
form of minute bubbles, in the walls of which the bacilli 
may be found. In man it produces the condition which 
has been described as gaseous gangrene, infectious emphy- 
sema, gas phlegmon, and emphysematous necrosis. 

Actinomyces, or Ray Fungus. — This organism probably 
belongs to the higher order of bacteria, and occurs in 
yellow masses, which may be visible to the naked eye. 
The masses consist of organisms with diverging rays, 
consisting of threads with bulbous ends (Fig. 233). It 

Fig. 233. 




Actinomyces. (Baumgarten.) 

occurs rarely in man, commonly in the lower animals, 
from which it has been obtained in pure culture. When 
implanted in the tissues, to which it is conveyed through 
a wound or carious tooth, sometimes apparently in seeds 
or in grains, it excites a chronic inflammation, with the 
presence of granulation-tissue, necrosis, and suppuration. 
In man it occurs most frequently in the mouth, tongue, 
and internal organs. In cattle it affects the jaws, causing 
" lumpy jarv." 



294 ASEPSIS AND ANTISEPSIS. 

Mycetoma, or the Streptothrix Madura. — This is a 
branching micro-organism, resembling the actinomyces, 
and, like it, occurring in granular masses composed of 
branching threads. It causes in the foot especially, the 
formation of nodular masses, which break down and form 
abscesses and fistulae, and often produces caries and necrosis 
of the bones. 



THEORY OF ASEPSIS AND ANTISEPSIS IN WOUND 
TREATMENT. 

Before the introduction of Lister's method of treat- 
ing wounds, it was the rule in accidental and operative 
wounds to have profuse suppuration, fever, pain, and in 
many cases such wound complications as septicaemia, 
pyaemia, erysipelas, and hospital gangrene, and the mor- 
tality following operative and accidental wounds was very 
high. The mortality in compound fractures from sepsis 
was formerly great, but by modern methods of wound 
treatment has been diminished to an insignificant percent- 
age. The same diminished mortality has followed ampu- 
tations and other wounds, accidental or operative. 

Lister's method of wound treatment was largely based 
upon the idea that the infection of the wound occurred 
from contact with the air, which contained spores and 
germs, and his method of treatment was chiefly directed 
to their destruction. The air may be a medium of wound 
infection to a certain extent, for it has been demonstrated 
that dry air contains dust in which spores and bacteria 
are present in much larger numbers than in moist air, and 
such air coming in contact with an open wound deposits 
there numbers of bacteria, which may set up inflammatory 
changes. Koch later demonstrated the fact that atmos- 
pheric microbes were chiefly of an innocuous character, 
and that wound infection was generally caused by bacteria 
or spores being brought in direct contact with the wound 
by the clothing and skin of the patient, the instruments 



SEPSIS. 295 

and the hands of the surgeon and assistants, and unclean 
surgical dressings. 

Cheyne has shown that the relative number of bacteria 
entering the tissues is an important factor in producing 
suppuration and septic infection, for we know that bacte- 
ria may exist in an aseptic wound and yet the wound heal 
and remain aseptic, the antiseptic qualities of the blood- 
serum and the cell-activity in healthy tissues being suffi- 
cient to destroy or remove a certain number of micro- 
organisms, and suppuration or septic infection occurring 
only when the tissues are overwhelmed by the number of 
organisms or when their power of resistance is diminished 
by injury or disease. This explains the satisfactory be- 
havior of wounds which pursue an aseptic course where 
very imperfect details of aseptic or antiseptic treatment 
have been employed. It may, therefore, be assumed that 
infection does not necessarily depend upon the presence of 
a few microbes, but rather upon the quantity and quality 
of the germs which are present in the wound. 

Pyogenic micro-organisms under different conditions 
may produce a series of different diseases, for it is now 
generally accepted that Fehleisen's streptococcus erysipe- 
Icitis is identical with streptococcus pyogenes, which is recog- 
nized as the cause of very different inflammatory affec- 
tions. The theory has been advanced by Eeger that all 
the so-called pus-diseases arc simply local expressions 
of a general infection caused by many different micro- 

o ... 

organisms. 

Sepsis. — Sepsis is due to the entrance and multiplica- 
tion of micro-organisms, or the absorption of their products 
in the body, and is characterized by local inflammation of 
the wound, and marked constitutional symptoms, such as 
fever, disorders of the nervous system, and inflammation 
of the viscera. Microbic infection represents a patholog- 
ical process which causes serious wound complications, and 
differs materially from that process which attends the re- 
pair of wounds that run an aseptic course. Aseptic chem- 
ical irritation of the tissues may result in the production 



296 ASEPSIS AND ANTISEPSIS. 

of a puruloid fluid, which is not pus. but merely a fibrinous 
exudation containing numerous cells, and does not produce 
infection if injected into animals. Acute suppuration in a 
wound is considered clinically to be always due to the 
presence of bacteria, for their exclusion will prevent its 
occurrence. 

Asepsis. — Asepsis aims at thorough sterilization of the 
field of operation and of all objects brought in contact with 
the wound, and the exclusion of micro-organisms by oc- 
clusive sterilized dressings. 

Antisepsis, on the other hand, has in view the destruc- 
tion of micro-organisms by keeping germicidal agents con- 
stantly in contact with the wound. The object of anti- 
sepsis is, therefore, to produce asepsis. 

Xo surgeon should undertake the performance of an 
operation or the treatment of an open wound without hav- 
ing clearly impressed upon his mind the important part 
that pyogenic and specific micro-organisms may play in the 
subsequent course of the wound. 

Methods of Disinfection or Sterilization. 

Since the majority of wound complications are due to 
the presence in the wound of micro-organisms, it is the 
duty of the surgeon to prevent their contact with it, or to 
employ means for their destruction. We must, however, 
employ means of disinfection or destruction of these micro- 
organisms which will not have any injurious effect upon 
the tissues with which they come in contact. Mechanical 
disinfection or sterilization is not applicable to wounds, but 
is emploved to remove any micro-organisms which may be 
present upon the objects which are to come in contact with 
the wound, namely, the hands of the surgeons and assist- 
ants, instruments, and the skin surrounding the wound. 
Mechanical disinfection is accomplished by the use of fric- 
tion with a brush, soap, and water. Germicidal solutions 
may be used for disinfection of wounds, but are most use- 
ful in the disinfection of the hands of the operator, the skin 



ANTISEPTIC METHOD. 297 

of the patient, the instruments, and the dressings. If 
these have been carefully employed before the wound 
is made, their subsequent use in the wound is usually 
unnecessary. 

Some forms of bacilli contain spores which resist the 
action of germicidal substances, while the bacilli them- 
selves are readily destroyed by these agents : the surgeon 
should, therefore, employ that means of disinfection which 
is generally applicable to the destruction of both bacilli 
and their spores. The bacilli of anthrax, tuberculosis, sad 
tetanus contain spores; hence to destroy these organisms 
is a matter of more difficulty than to render harmless such 
micro-organism- as staphylococcus pyogenes aureus, albus, 
and citreuSj streptococ rus pyogenes and streptococcus erysip- 
elatis, and the bacilli of diphtheria and glanders, which 
contain no spores. 

Heat when used as a germicide cannot be applied to the 
wound itself, except in cases where a limited surface of 
the wound may be touched with the hot iron. Heat can, 
therefore, be used only for the disinfection of -ubstances 
coming in contact with the wound, and for this purpose 
it is employed in the form of steam, dry heat, or boiling 
water. 

Sterilization of the wound or the sub-tanees coming in 
contact with it may be accomplished by using either the 
aseptic method or the eratisepAic method, and at the present 
time these two methods are to a certain extent combined — 
that is. it is impossible to be strictly aseptic without em- 
ploying means of disinfection by the use of antiseptics. 
The aseptic method, which employs germicidal substances 
only fir the purpose of sterilization of objects coming in 
contact with the wound when their disinfection by heat 
is impossible, is the method which has generally been 
adopted. 

Antiseptic Method. — In the antiseptic method the 
sterilization of the field of operation, the hands of the 
surgeon and assistant-, the instruments, ligature?, sponges. 
and sutures, is accomplished by the use of germicidal 



298 ASEPSIS AND ANTISEPSIS. 

solutions, and, in addition, the wound is irrigated fre- 
quently during the operation with germicidal solutions, 
and is afterward covered with dressings impregnated with 
germicidal substances. The antiseptic method was that 
first employed, and, recognizing its value in surgical pro- 
cedures, many surgeons still continue to employ this 
method ; but it has certain disadvantages. Recent inves- 
tigations have shown that many germicidal substances 
have not the power which Avas formerly attributed to 
them, as they only arrest bacterial development ; many 
chemical germicides cause the formation of a dense layer 
of coagulated albumin around albuminous substances, and 
also fail to destroy micro-organisms associated with fatty 
or oily substances. Chemical germicides may also form 
combinations in the tissues with substances with which 
they come in contact, seriously impairing their germicidal 
action. Antiseptic substances which are active as germi- 
cides often cause irritation of the surface of the wound, 
interfering with its repair. 

It has been shown that irrigation of a fresh wound with 
a 1 : 10,000 solution of bichloride of mercury is followed 
by distinct evidence of superficial necrosis of the tissues. 
Antiseptic irrigation of wounds is apt to cause very free 
oozing of serum, which necessitates the use of drainage, 
and makes frequent dressing of the wound necessary. 
Many antiseptic substances produce marked toxic effects 
upon the patient, and also cause severe irritation of the 
skin with which they come in contact. 

Aseptic Method. — In employing the aseptic method 
in the treatment of wounds, the field of operation, the 
hands of the surgeon and assistants, the instruments, liga- 
tures, sponges, and sutures, are sterilized by the use of 
germicidal solutions and heat, and after this has been 
accomplished, relying upon the completeness of the steril- 
ization, no germicidal substances are brought in contact 
with the wound, sterilized water or sterilized salt solution 
being used if it is necessary to flush the wound, and the 
dressings employed are those only which have been ster- 



HEAT. 299 

ilized by moist or dry heat. The advantages of the 
aseptic method are as follows : the method is applicable to 
all parts of the body ; wounds treated by this method heal 
more promptly and do not require frequent dressing ; there 
is no risk of toxic effects, and there is no irritation of the 
skin by the dressings. Dry sterilized dressings are effi- 
cient to produce absorption, and at the same time the 
dryness may be a factor in the destruction of germs, 
for depriving bacteria of moisture robs them of one of 
the conditions necessary to their existence. The aseptic 
method is, therefore, to be preferred to the antiseptic 
method in the treatment of wounds wherever it is possible. 

Agents Employed to Secure Asepsis. 

A great variety of agents possessing more or less 
germicidal properties have been at different times em- 
ployed in the practice of aseptic or antiseptic surgery ; 
those most employed at the present time are heat, bichlo- 
ride of mercury, carbolic acid, iodoform, formalin, beta- 
naphthol, formaldehyde, chloride of zinc, acetate of 
aluminum, peroxide of hydrogen, kreolin, permanganate 
of potassium, sulphorarbolate of zinc, salicylic and boric 
acids, acetanilid, aristol, and certain silver salts. 

Heat. — The most reliable and universally available 
agent for the destruction of micro-organisms is heat, either 
dry or moist ; many forms of bacteria are rendered inert 
at a temperature of 140° F., and none can withstand the 
application of moist heat at 212° F. continued for a short 
time. Spores which will resist the action of powerful 
germicides for a considerable time are destroyed by boil- 
ing for a few minutes. Dry heat is not as efficient for 
sterilization as moist heat, for some spores will resist dry 
heat of 284° F. for three hours. As moist heat is the 
most efficient sterilizer, it should be preferred, and can 
always be made use of for this purpose by boiling the 
instruments and dressings for a few minutes ; and if for 
liny reason it is thought advisable to employ dry heat as 



300 



ASEPSIS AND ANTISEPSIS. 



Fig. 234. 




Steam sterilizer. 



a sterilizer, this may be made use of by baking the instru- 
ments or dressings in a hot oven. The best results may 
be obtained by the use of one of the various dry or moist 

sterilizers (Fig. 234). An 
improvised sterilizer may be 
made by placing a perforated 
metal stand inside a large 
kettle, so that only the steam 
comes in contact with the 
instruments and dressings. 

Bichloride of Mercury. 
— This is employed as an 
antiseptic in watery solu- 
tions varying in strength 
from 1 : 500 to 1 : 10,000. 

The solution of 1 : 500 to 
1 : 1000 is used only for the 
irrigation and disinfection of 
the hands and skin ; for the 
irrigation of wounds, a solution of 1 : 2000 or 1 : 4000 
may be employed. At the present time bichloride solu- 
tions are not frequently used in fresh wounds, on account 
of their irritating effects. Where continuous irrigation is 
kept up, or where it is employed in large cavities, a still 
weaker solution, 1 : 5000 to 1 : 10,000, should be employed. 
In using bichloride solutions the surgeon should watch 
the patient carefully for signs of poisoning due to absorp- 
tion of the bichloride of mercury ; the symptoms denoting 
this are vomiting, fetid breath, salivation, inflammation 
of the gums, diarrhoea, blood-stained stools, and bleeding 
from the mouth and nose. Locally the use of moist bi- 
chloride dressings may cause well-marked dermatitis. The 
continuous application of bichloride solution to the hands 
of the surgeon causes the skin to become roughened and 
blackens the nails. 

In preparing solutions of bichloride of mercury for use, 
it will be found convenient to have a concentrated solu- 
tion of the salt in alcohol, 1 part of the bichloride to 10 
parts of alcohol ; this can be kept in a well-stoppered 






CARBOLIC ACID. 301 

bottle, and to it should be added one teaspoonful of com- 
mon salt, which prevents disintegration of the mercuric 
compound. One teaspoonful of this solution added to one 
quart of water makes a 1 : 2500 solution. 

A 10 per cent, bichloride solution may be made as fol- 
lows : 

Bichloride of mercury 2 parts. 

Sodium chloride 1 part. 

Dilute acetic acid 1 " 

Aquae dest 16 parts. 

By adding water in an appropriate quantity, a 1 : 1000 or 1 : 2000 
solution can be made. 

Or the solution may be prepared with tartaric acid in 
the proportion of 5 parts of the acid to 1 part of bi- 
chloride of mercury, the following formula being em- 
ployed : 

Hydrarg. chlor. corrosiv grs. xv. 

Ac. tartaric grs. lxxv 

Aquas dest Oij. 

Pellets containing a definite amount of bichloride of 
mercury compounded with a few grains of common salt of 
muriate of ammonium, which, when dissolved in a definite 
quantity of water, make a solution of 1 : 1000 or 1 : 2000, 
will also be found very convenient for the preparation of 
solutions. The pellets should also contain a little coloring- 
matter, which gives a faint color to the solution and serves 
to distinguish it from other solutions. 

Carbolic Acid. — This drug is employed in solutions of 
1 : 20 or 1 : 40. The stronger solution, 1 : 20, is usually 
employed to sterilize instruments, the latter being allowed 
to remain in this solution for thirty minutes before being 
used. As a carbolic solution of this strength benumbs 
and cracks the skin of the hands of the operator, it should 
be diluted just before the instruments are required, by 
adding an equal quantity of boiled water, making it a 
1 : 40 solution. The rusting of steel instruments and the 
dulling of the edges of knives by exposure to carbolic 
acid may be prevented by the addition of 5 per cent, of 
sodium carbonate to the solution. 



302 ASEPSIS AND ANTISEPSIS. 

The 1 : 40 or 1 : 60 solution is used for the irrigation of 
wounds and the washing of sponges. As carbolic acid in 
strong solutions is a local caustic and coagulates albumin, 
it should not be used in fresh wounds. A ready method 
of making a 5 per cent, carbolic solution is to add one 
tablespoon ful of carbolic acid to one pint of hot water. 

In using carbolic acid solutions continuously, the sur- 
geon should be on the watch for symptoms of poisoning, 
which will be manifested by dark-colored urine, head- 
ache, dizziness, vomiting, and in severe cases bloody diar- 
rhoea, hemoglobinuria, and death from collapse. Carbolic 
acid solutions should be used with great caution in young 
children, as they seem to be more susceptible than adults 
to its constitutional effects. 

The use of weak solutions of carbolic acid seems to 
involve more risk of toxic action than does the employ- 
ment of the pure drug, the superficial layer of tissue being 
coagulated by the latter, so that absorption of the drug 
is prevented. Gangrene of the skin and subjacent tissues 
has frequently been observed to follow long-continued use 
of quite dilute solutions of carbolic acid or of ointments 
containing small quantities of the drug. Cases of gan- 
grene of the fingers and toes from this cause are not infre- 
quently seen. 

Iodoform. — Iodoform has been shown by experimental 
research to possess little direct germicidal action, but in 
spite of this fact clinical experience has proved that it 
possesses powerful antiseptic properties, due, as shown by 
Behring and De Ruyter, not to the destruction of germs, 
but to its undergoing decomposition in their presence, 
and thus rendering inert the ptomaines which have re- 
sulted from the germ-growth. It may be rendered abso- 
lutely sterile by exposing it to heat, and, as it is easily 
decomposed, fractional sterilization may be employed, or 
by washing it in a 1 : 1000 bichloride solution ; it should 
then be dried and kept for use in closely stoppered bottles. 
Iodoform is often employed in the form of a powder as an 
application to wounds, and is frequently used in aseptic 
wounds which are liable from their position to become in- 






FORMALIN. 303 

feeted, such as those about the mouth, rectum, aud vagina, 
and is especially useful as a dressing in infected wounds 
and in tubercular or syphilitic ulcers and in bone cavities. 
In operations upon the mouth, anus, rectum, uterus, and 
abdominal cavity iodoform gmize packing is largely em- 
ployed, and serves to keep the discharges from becoming 
foul, thus often preventing septic intoxication ; it must, 
however, be used with caution in the mouth. Iodoform 
collodion, made by adding iodoform, gr. xlviii, to col- 
lodion, 15J, is a useful dressing in superficial wounds. 
Iodoform may also be employed in the form of an ethereal 
solution, iodoform, gr. xv; ether, f.sj, as an application 
to wounds or ulcer-. An emulsion of iodoform in glyc- 
erin, iodoform. 3J ; -terilized glycerin, .~x. or an emul- 
sion of iodoform made by adding sterilized iodoform. ,~j, 
to 1 )«>iled olive oil. £x 3 i- much employed as an injection 
in the treatment of tubercular abscesses and joints. For 
packing cavities, a 5 per cent gauze is best : a 10 percent. 
gauze i- t<"> strong except in small amounts. For large 
cavities a Mikulicz jx"-/:, consisting of a bag of iodoform 
gauze stuffed with sterilized gauze, may be employed. 

Numerous cases have been reported in which toxic symp- 
toms have followed the use of iodoform, such as urtica- 
rial eruption-, dermatitis, headache, depression, delirium, 
mania, debility, and sleeple-snes-. Elderly persons aud in- 
fants are very susceptible to the toxic action of iodoform. 

Formaldehyde. — This i- a pungent, penetrating gas, 
p 5S ssing valuable antiseptic properties, which is prin- 
cipally used for the disinfection of clothing, instruments, 
bedding, and room.-. The gas is generated in a lamp or 
generator by passing the vapor of methyl alcohol over a 
coil of glowing platinum wire or gauze, or over platinized 
asbestos. 

Formalin. — This is a 40 per cent, solution of formal- 
dehyde gas in water, and has valuable antiseptic proper- 
ties. A solution of this strength is a powerful irritant, and 
should not be used in the treatment of wounds. It may 
be used in a 2 per cent, solution to disinfect wounds or 
instruments, or in 0.25 per cent, solution for irrigation. 



304 ASEPSIS AND ANTISEPSIS. 

Brewer recommends a 1 per cent, solution applied for three 
minutes to disinfect the skin, a 2 per cent, solution, applied 
under anaesthesia, to sterilize infected tissues, and 0.3 per 
cent, solution for gauze. 

Beta-naphthol. — Beta-naphthol, in a 1 : 2500 solution, 
is employed for much the same purposes as bichloride of 
mercury solutions ; it is not, however, so powerful a germi- 
cide. It is employed in irrigating large cavities, because 
it is not a poisonous agent, and is especially useful as a 
bath for instruments, as it does not corrode them, as do 
sublimate solutions. It may be employed as a dusting- 
powder on sloughing surfaces, and especially to wounds 
exposed to feces or urine. It also possesses the advantage 
over a carbolic acid solution of not irritating the skin of 
the surgeon's hands. 

Silver Salts. — Silver lactate (actol) and silver citrate 
(itrol) are two antiseptics which have been recommended 
by Cred6, who considers their germicidal properties supe- 
rior to those of bichloride of mercury. These salts may be 
used in a 1 : 4000 or 1 : 8000 solution, which should be 
made with water free from chlorides, which precipitate the 
silver ; distilled water should be employed. Crede speaks 
highly of an ointment made of metallic silver, which may 
be employed as an inunction in septic diseases. 

Acetanilid. — This preparation possesses antiseptic prop- 
erties, and is frequently used as a substitute for iodoform. 
It may be used in the form of powder as an application to 
suppurating or ulcerating tissues, but in tubercular condi- 
tions is not as satisfactory as iodoform. 

Chloride of Zinc. — Chloride of zinc, in a solution of 
30 to 40 grains to water f^j, is a very powerful antiseptic. 
When employed upon raw surfaces it produces marked 
blanching of the tissues ; it is especially useful in wounds 
which are infected or which have been exposed to infec- 
tion. I have found it by all means the best application 
for the poisoned wounds which are received in dissect- 
ing dead bodies and in operating. In such cases the 
whole cavitv or surface of the wound should be washed 



KREOLIN. 305 

with a 30-grain solution, and then the wound should be 
dressed with moist bichloride gauze. 

Sulphocarbolate of Zinc. — This drug has been found 
to possess more decided antiseptic properties than the chlo- 
ride of zinc, and is much less irritating. It may be used 
in the same strength and for the same purposes as the 
latter drug. 

Acetate of Aluminum. — This drug is used in solution, 
and is prepared as follows : aluminis, Syj (24 grammes) ; 
plumbi acetatis, gixss (38 grammes) ; aqua?, Oij (1000 
grammes). Mix, and filter after standing twenty-four 
hours. It has decided germicidal qualities, is employed for 
irrigation and moist dressing where carbolic or bichloride 
solutions cannot be used, and is by all means the safest 
and best antiseptic substance for wot dressings. 

Peroxide of Hydrogen. — Peroxide of hydrogen is em- 
ployed in what is known as the 15- volume solution. It 
may be used in this strength or may be diluted. It seems 
to have a direct action upon pus-generation by destroying 
the micro-organisms of pus, and is frequently employed in 
the sterilization of sinuses or suppurating cavities, such as 
remain after the opening of abscesses or result from dis- 
eases of or operations upon the bones. It is injected into 
the sinuses and cavities by means of a glass syringe, or 
may be applied to open wounds in the form of a spray. 
Its action is shown by the escape of bubbles of gas, which 
cleanse suppurating surfaces or sinuses mechanically, and 
it should be used as long as these continue to escape. 

Pyrozone. — Pyrozone possesses the same qualities as the 
peroxide of hydrogen, and apparently to a somewhat higher 
degree, and is used for the same purposes. 

Kreolin. — This substance is obtained from English coal 
by dry distillation, and has been found to possess powerful 
germicidal properties ; it is non-irritating and practically 
non-toxic. It is insoluble in water, but forms an emul- 
sion with it which possesses marked antiseptic properties. 
It is especially useful as a deodorant in offensive malig- 
nant ulcers. It may be employed for the same purposes 
as carbolic acid. It is used in an emulsion, in strength 

20 



306 ASEPSIS AND ANTISEPSIS. 

of from 2 to 5 per cent., and is employed in the irrigation 
of large wounds or cavities of the body, and has been 
most favorably recommended in gynecological practice. 

Boric Acid. — This drug has not very marked antiseptic 
qualities, and is usually unirritating even in saturated 
solutions ; but occasionally it produces marked irritation 
of the skin. It is frequently employed in a 5 per cent, 
solution to cleanse and disinfect mucous surfaces and large 
cavities. It is often employed to wash out the bladder 
before the operation for the removal of calculi or growths 
from that organ. In the dressing of superficial wounds, 
or in wounds in which the bichloride or carbolic acid 
dressings produce irritation, an ointment of boric acid, 1 
part, to petrolatum 5 parts, will be found very satisfactory. 

Boro-salicylic Powder. — This powder, which consists 
of 4 parts of boric acid to 1 part of salicylic acid, is used 
as a dusting-powder and as a dressing for w T ounds. It has 
been recommended highly by Senn in the treatment of 
fresh wounds. 

Salicylic Acid. — Salicylic acid does not have very 
marked antiseptic qualities, but possesses much less toxic 
action than carbolic acid, and is used for somewhat the 
same purposes. Its antiseptic power is said to be increased 
by the addition of boric acid, and a boro-salicylic lotion 
(Thiersch's solution) is prepared by adding salicylic acid, 
1 part ; boric acid, 6 parts ; to hot water, 500 parts, mak- 
ing a bland solution, which, when reduced to 25 to 50 per 
cent, of the original strength, may be used for irrigation 
of the bladder or the peritoneal cavity. 

Permanganate of Potassium. — This drug, owing to its 
rapid absorption of oxygen, acts as an antiseptic, and is 
often employed for the disinfection of foul wounds and 
ulcers. It is employed also in solution for washing the 
operator's hands and for the washing of sponges. It is 
practically non-irritating, and may be used in quite con- 
centrated solutions, but is usually employed in the follow T - 
ing strength : permanganate of potassium, £j ; water, f^j. 
One fluidrachm of this solution to a pint of water makes 
a 1 : 1000 solution. 



STERILIZATION OF WATER. 307 

Aristol. — Aristol, which is a compound of iodine and 
thymol, possesses germicidal properties, and has been in- 
troduced as a substitute for iodoform. It has the advan- 
tage over iodoform of not being poisonous, and is also 
without disagreeable odor. It may be employed for the 
same purposes as iodoform, and it seems to be particularly 
useful as a dressing to chronic and specific ulcers. 

Orthoform. — This is a colorless powder which is slightly 
soluble in water. It possesses decided antiseptic properties 
as well as a local anaesthetic action. It is employed as a 
dressing for small wounds, burns, and ulcers. As it pos- 
sesses toxic action, it should not be used where there is an 
extensive raw surface. 

Sodium Chloride. — This salt has no direct antiseptic 
action, but is used in the preparation of normal salt or 
saline solution, the strength of which is 0.6 per cent. 

Saline Solution. — This is prepared by adding 6 drachms 
of sterilized sodium chloride to 1 litre of distilled water, 
which is contained in a sterilized oval glass flask. The 
mouth of the flask should be plugged with sterilized cotton, 
and a piece of gauze fastened over the mouth and neck of 
the bottle. The solution should be exposed to steam ster- 
ilization one-half hour on two successive days. Saline 
solution is non-irritating, and is frequently used in the irri- 
gation of fresh wounds, to remove foreign bodies or blood, 
and for the cleansing of mucous and serous surfaces. Its 
utility by intravenous injection or infusion is well recog- 
nized (see page 147). In emergencies a solution prepared 
by adding a drachm of common salt to a pint of water 
which has been sterilized by boiling, may be employed. 

Sterilization of Water.— Water may be rendered abso- 
lutely sterile by boiling from fifteen to thirty minutes. It 
should be distilled or filtered before being boiled, to re- 
move any inert matter which is not desirable in wounds. 
After being boiled, it should be placed in sterilized glass 
flasks, and corked with sterilized cotton, the mouths of the 
flasks also being covered with several layers of gauze. 
It is employed for the irrigation of wounds and of mucous 
and serous surfaces. 



308 ASEPSIS AND ANTISEPSIS. 



PREPARATION OF MATERIALS USED IN ASEPTIC 
OPERATIONS. 

Sponges. — Marine sponges are the best materials for 
the purpose of sponging, but their satisfactory sterilization 
is often a matter of difficulty. It is better to use a cheap 
grade of sponges, and to use them only once. The steril- 
ization of sponges by boiling destroys to a certain extent 
their elasticity and their absorbent power. Elsberg claims 
that sponges can be boiled in the following solution with- 
out losing their properties : caustic potash, 1 per cent. ; 
tannic acid, 2 per cent. ; water, 97 per cent. Schimmel- 
busch recommends the following method : The dried 
sponges are freed from dirt or sand by beating, and are 
then soaked for several days in cold water slightly acidu- 
lated with hydrochloric acid, being kneaded from time to 
time. They are next thoroughly washed in cold and in 
warm water, wrapped in a linen sheet, and placed in a 
boiling 1 per cent, soda solution ; the solution should not 
be allowed to boil after the sponges are placed in it. They 
are allowed to remain in this hot solution for thirty min- 
utes, are then washed in boiled water to remove the soda, 
and placed in a 0.5 per cent, bichloride solution until 
needed. 

Another method of preparing sponges consists in beat- 
ing them to remove any sandy matter which they may 
contain, and placing them for twenty-four hours in a solu- 
tion of hydrochloric acid, 4 ounces ; water, 4 pints ; upon 
removing them from this solution they are washed until 
free from acid ; they are then placed for ten minutes in the 
following solution : potassium permanganate, 5ij ; sodium 
sulphate, 3j ; hydrochloric acid, ^ij ; distilled water, Oij. 
They are then removed and placed in running water for 
six hours, and afterward in a 5 per cent, carbolic acid 
solution or a 1 : 1000 bichloride solution. Carbolic solu- 
tion is the better one, as it is not so liable to decomposition. 

Gauze Pledgets or Pads. — On account of the difficulty 
in satisfactorily^ sterilizing sponges, as well as of their 



MATERIALS USED IN ASEPTIC OPERATIONS. 309 

expense, folded gauze pledgets have largely superseded 
them. 

Gauze Pledgets. — Gauze pledgets are prepared by cutting 
a piece of gauze, composed of from twelve to sixteen layers, 
in pieces six inches square ; the four angles of these pieces 
are then tied together or secured by a few stitche-. 

Gauze Pads. — Gauze pads are made from a piece of gauze 
composed of from sixteen to twenty layers cut the desired 
size, the different layers in each pad being quilted together 
by a few stitches, and the edges loosely whipped witli a 
thread to prevent them from fraying. Gauze pads are 
used as a substitute for the flat sponges formerly employed 
in abdominal surgery, and for the drying of wounds. 
Where pads are used in abdominal operations, to prevent 
them from being lost in the abdomeu it is well to have 
sewed to each pad a piece of tape twelve inches in length, 
which is allowed to protrude from the wound, and to 
which a hemostatic forceps is attached. The pads or pled- 
gets may be sterilized by boiling or by exposure to steam 
or dry heat in a sterilizer, or may be sterilized and pre- 
served for some time in a 1 : 2000 bichloride solution. 
When so preserved, before being employed the moisture 
should be squeezed from them, and they should be washed 
in sterilized water before being brought in contact with the 
wound. Sterilization by steam is the safest method. 

Silk Sutures and Ligatures. — Silk for sutures or 
ligatures, either the plaited silk or the Chinese twisted 
silk, should be sterilized by boiling from ten to thirty 
minutes in a 5 per cent, solution of carbolic acid, or in 
water, the time of boiling depending upon the thickness 
of the threads ; frequent boiling renders the silk weak. 
It should then be placed in stoppered bottles and covered 
with a 5 per cent, solution of carbolic acid or with abso- 
lute alcohol, or in 1:1000 bichloride and alcohol solution. 

Silkworm-gut. — Silkworm-gut is an excellent material 
for sutures, and may be sterilized by boiling it for fifteen 
minutes, or by placing it for one-half hour in a 5 per 
cent, carbolic solution ; after being sterilized, it should be 
kept in 95 per cent, alcohol. There has recently been 



310 ASEPSIS AND ANTISEPSIS. 

introduced an iron-dyed black silkworm-gut, which makes 
the sutures more prominent and thus facilitates their 
removal. 

Catgut Ligatures and Sutures. — Catgut is the ideal 
material for ligatures and sutures, but has the disadvan- 
tages of difficulty and uncertainty in its sterilization. 
Raw catgut is often infected with micro-organisms, and, 
therefore, thorough sterilization alone can render it a safe 
material for ligatures and sutures. 

Von Bergmann's Catgut. — This method of preparing 
catgut, which we have found one of the most satisfactory, 
consists in winding the catgut loosely upon glass rods or 
spools ; these spools are placed in ether for twenty-four 
hours ; the ether is then poured off, and they are placed in 
the following solution : bichloride of mercury, 10 parts ; 
absolute alcohol, 800 parts ; distilled water, 200 parts. 
Remove from this solution after twenty-four hours, and 
place them in a similar solution for forty-eight hours ; then 
place in absolute alcohol. If soft catgut is desired, add 
20 per cent, of glycerin to the absolute alcohol. To 
make the sterilization absolutely certain, it has been found 
advantageous to soak the catgut for thirty minutes in a 
1 : 1000 aqueous bichloride solution before placing it in 
the alcoholic solution of bichloride. 

Dry Sterilized Catgut. — Boeckman's process for steriliz- 
ing catgut consists in cutting the gut in pieces twenty to 
forty inches in length, wrapping each piece in paraffin- 
paper and sealing in a paper envelope. The envelopes are 
then placed in a steam sterilizer for three hours at a tem- 
perature of 284° F., and then for four hours longer at a 
temperature of 290° F. When required for use, the en- 
velope is opened, the paraffin-paper removed, and the gut 
immersed for a few minutes only in sterilized water. 

Boiled Catgut. — Catgut may also be sterilized by boil- 
ing in alcohol under pressure. The most satisfactory 
method is that devised by Fowler, Avhich consists in plac- 
ing a number of strands of catgut in an ordinary test-tube 
which is filled with 95 per cent, alcohol to within half an 
inch of the top ; a wad of cotton is next pushed into the 



MATERIALS USED IX ASEPTIC OPERATIONS. 311 

mouth of the tube, and a cork is introduced. The tubes 
thus prepared are placed inverted in a fruit-jar filled with 
95 per cent, alcohol ; the jar is then closed and placed in 
a water-bath, and kept at a boiling temperature for an 
hour. Or the catgut may be loosely wound upon glass 
r<:»ds and spools, and placed in a metallic cylinder or jar 
having an accurately fitting screw-top. The catgut is 
then covered with absolute alcohol, the top is screwed 
down, and the cylinder or jar is immersed in boiling 
water for an hour. 

Formalin Catgut. — This is prepared by Minding catgut 
loosely on glass spools and keeping them for forty-eight 
hours in a vessel containing equal parts of alcohol and 
ether. Thev should next be washed for a few minutes in 
alcohol and placed in a jar containing equal parts 
alcohol and formalin, and allowed to remain for several 
days. The excess of formalin should then be washed 
away with alcohol, and the catgut kept for use in 95 per 
cent, alcohol. 

Cumol Catgut. — The catgut is rolled loosely on glass 
spools, which are placed in a glass beaker having a layer 
of cotton in the bottom : the beaker is covered by a piece 
of cardboard having a hole in the centre through which a 
thermometer is introduced, and is placed on a Band-bath 
heated by a Bnnsen burner. Heat is applied until the 
temperature is raised to 170 : F. ; this i- maintained for 
one hour, and removes all moisture from the catgut. 
Cumol. at a temperature of 21 2 : F.. i- next poured into 
the beaker, completely covering the catgut, and the tem- 
perature is then raised to 329' F. and maintained for one 
hour. The cumol is next poured off, and the catgut is 
allowed to dry in the beaker on the sand-bath at a tem- 
perature of 21 2 C F. for two hours; it is then transferred 
to sterile jars or tubes, which should be air-tight. 

Elsberg's Method of Sterilizing Catgut. — The catgut is 
immersed for forty-eight hours in a mixture of 1 part 
of chloroform to 2 parts of alcohol, then wound loosely 
upon spools and boiled for thirty minutes in a saturated 
solution of ammonium sulphate, and upon its removal 



312 ASEPSIS AND ANTISEPSIS. 

from this solution it should be immersed in sterilized 
water to remove crystals of ammonium sulphate. It may 
then be preserved in absolute alcohol. 

Iodine Catgut. — This variety of catgut has recently 
been extensively used with most satisfactory results. The 
catgut is soaked in a 1 per cent, solution of iodine for seven 
days, when it is ready for use. The solution is prepared 
by dissolving iodide of potassium, 1 part ; iodine 1 part in 
100 parts of water. The solution is prepared by dissolv- 
ing the iodide of potassium in a small quantity of water, 
to which the iodine, finely powdered, is added and the 
concentrated solution is diluted to a 1 per cent, solution. 

The catgut may be kept in the sterilizing solution or in 
a mixture consisting of absolute alcohol 950, glycerine 50, 
iodoform, finely powdered, 100. 

If preserved in the iodine solution the gut is washed 
in a solution of carbolic acid, 3 per cent., or in some indif- 
ferent sterile solution before being used. 

Chromic Acid or Chromicized Catgut. — Catgut, after 
being soaked in ether for twenty-four hours and washed 
in alcohol, is placed for twenty-four hours in a 4 per cent, 
aqueous solution of chromic acid ; it is then removed and 
dried in a hot oven, and placed in closely stoppered jars, 
or may be preserved in absolute alcohol. Catgut thus 
prepared will resist the action of living tissues for several 
weeks, the time of its absorption depending upon the size 
of the gut. Before being used, it should be sterilized by 
either the cumol, alcohol, or formalin method. 

Owing to the fact that it undergoes very slow solution 
in the tissues, chromicized catgut is often employed for 
sutures or for the ligation of the larger vessels in their 
continuity, and for bone sutures. 

A very simple method of carrying catgut and keeping 
it sterile consists in using a strong glass tube, about an 
inch in diameter and six inches in length, into each end 
of which is fastened a rubber cork. A number of glass 
spools wound with sterilized catgut of various sizes are 
fitted into this glass tube, and one cork is introduced ; the 
tube is then filled with alcohol or a 1 : 2000 bichloride 



MATERIALS USED IN ASEPTIC OPERATIONS. 313 



solution in alcohol, and the other cork is introduced, or a 
test-tube and a rubber stopper may be used. 

Celluloid Thread. — This material, recently introduced 
by Pagenstecher, is prepared by boiling linen thread for 
thirty minutes in a 1 per cent, solution of sodium carbonate. 
It is then dried between sterile compresses and soaked for 
some hours in celluloid solution. It may be kept dry or 
in an alcoholic solution of bichloride of mercury. It may 
be resterilized by boiling or under steam pressure. It has 
proved a satisfactory material for sutures and ligatures, 
and may be used in place of catgut or silk. 

Drainage-tubes. — The drainage-tubes usually employed 
are prepared from rubber-tubing of different sizes perfor- 
ated at short intervals ; the black-rubber tubes are softer 
and more pliable than the red- or white-rubber tubes, and 



Fig. 235. 



Fig. 236. 





Rubber drainage-tube. 



Glass draiuage-tube. 



are generally preferred (Fig. 235). Drainage-tubes are also 
made of glass, straight or curved (Fig. 236), which are 



314 



ASEPSIS AND ANTISEPSIS. 



Fig. 23/ 




almost exclusively used in abdominal surgery, and also of 
decalcified bone. The tubes should be kept in a 5 per cent, 
solution of carbolic acid, or, if kept dry, they should be 
well washed and sterilized by boiling water for a few min- 
utes before being used. 

Cigarette Drain. — This consists of a roll of sterilized 
or iodoform gauze covered by rubber pro- 
tective tissue (Fig. 237). It may be pre- 
|J pared in lengths of twelve inches and a 
m sufficient amount cut off as is required by 

the depth of the wound to be drained. It 
is a very satisfactory form of drain in ab- 
dominal wounds. 

Catgut and Horsehair Drainage. — 
Catgut as ordinarily prepared for ligatures 
may be used to secure drainage in small 
and superficial wounds ; a number of strands 
are placed in the bottom of the wound, and 
the ends are allowed to project from one or 
both extremities of the wound. 

Horsehair may be employed for the same 
purpose, a number of strands of the hair 
being placed in the wound in the same 
manner. Before being used, it should be 
well washed with soap and water, and then 
soaked in a 5 per cent, carbolic solution or 
1 : 1000 bichloride solution for twenty-four 
hours. 

Protective. — Protective is employed to 
cigarette drain, prevent the wound from being irritated by 
the antiseptic substances with which the 
gauze is impregnated or by its irregular surface. The 
great objection to the use of protective is that it sometimes 
interferes with drainage, and permits of the accumulation 
of serum beneath it, which may become infected and cause 
infection of the wound. 

Various materials are employed as protectives, the prin- 
cipal requirement being that they can be readily rendered 
aseptic and do not absorb irritating materials from the 
dressings. 







MATERIALS USED IX ASEPTIC OPERATION'S. 315 

The protective first employed by Mr. Lister, which is 
still generally used, is prepared by coating oiled silk with 
copal varnish, and when this is dry a mixture of 1 part of 
dextrin, 2 parts of powdered starch, and 16 parts of a 
1 : 20 carbolic acid solution, is brushed over its surface. 
Rubber-tissue may be employed very satisfactorily as a 
substitute for this protective. 

Before applying the protective to the wound, it is soaked 
in a solution of bichloride of mercury or carbolic acid. 

Silver Foil. — The inhibitive action of metallic silver on 
the growth of micro-organisms is utilized in the employ- 
ment of silver foil t<> cover the surface of wounds. The 
foil is sterilized by dry heat and placed directly on the 
surface of the wound after it has been closed by sutures. 
It is claimed that the foil prevents infection of the wound 
from the exterior, and also destroys micro-organisms 
which may come in contact with it. 

Mackintosh. — This consists of cotton-cloth, with a thin 
layer of India-rubber spread on one side. It is employed 
in antiseptic dressings outside of the gauze, and should 
be applied with the rubber surface toward the wound, to 
prevent the entrance of air and to allow the serum from 
the wound to permeate the gauze, and not soak directly 
through the dressings. 

The mackintosh cloth is not at the present time as much 
employed as formerly, unless the method of moist dressing 
is adopted. 

Rubber-dam. — This is a thin, pure rubber-tissue, and 
as it has no cloth surface, like mackintosh, it may be 
cleansed and sterilized with greater facility. It is used in 
the method of moist dressing to cover the gauze dressings, 
and is attached to the drainage-tube in abdominal wounds 
to shut off the opening of the tube from the abdominal 
wound. Before being used, it should be washed with soap 
and water, rinsed, and then placed in a bichloride or car- 
bolic solution for a time sufficient to sterilize it. 

Rubber-tissue.— This consists of a very thin sheet of 
India-rubber with glazed surfaces, which can be obtained 
from the rubber-manufacturers : it is employed for the 
same purposes as the mackintosh, is much less expensive, 



316 ASEPSIS AND AXTISEPSI& 

and, as previously stated, may be used when properly 
sterilized instead of protective for covering the wound. 

Gauze Dressings. 

The most convenient and cheapest material for wound 
dressing is a material known to the trade as cheese-cloth 
or tobacco-cloth, and for surgical use should contain no 
sizing. From the fact that it has a very open mesh, it ab- 
sorbs well either the materials with which it is prepared or 
the discharges from the wound, and is soft and pliable, so 
that it is a comfortable form of dressing to the patient. 

Gauze containing various antiseptic substances was for- 
merly much employed in surgical dressings, but at the pres- 
ent time it has been largely superseded by sterilized gauze. 

Bichloride or Corrosive Sublimate Gauze. — Bichlo- 
ride or corrosive sublimate gauze is prepared by placing 
cheese-cloth in a washing-kettle and covering: it with 
water to which is added two pounds of washing-soda or a 
pint of lye; the latter is added to dissolve any oily matter 
which the cheese-cloth contains, thus making it more 
absorbent. The gauze is boiled in this solution for an 
hour, and is then removed and washed in boiled water 
and passed through a sterilized clothes-wringer ; it is then 
immersed in a 1 : 1000 bichloride solution for twenty-four 
hours ; the excess of fluid is then squeezed out of it, and 
it may be packed in air-tight jars and preserved as a moist 
gauze, or may be dried in a warm oven and packed in ster- 
ilized jars and kept as a dry gauze. Dry bichloride gauze, 
unless freshly prepared, possesses little antiseptic properties. 

In using the sublimate gauze on delicate skins a der- 
matitis sometimes results, which is known as mercurial 
eczema ; this is particularly apt to occur if the gauze is 
moistened or covered with rubber-tissue or mackintosh. 
If this condition develops, the parts covered by the gauze 
should be rubbed over with boric acid ointment or vase- 
line before it is reapplied, or a sterilized gauze dressing 
should be substituted. 

Iodoform Gauze. — This may be prepared by soaking 



MATERIALS USED IN ASEPTIC OPEBATIOXS. 317 

sterilized gauze in a mixture containing iodoform, 5 part? ; 
glycerin, 20 parts ; and alcohol, 75 parts. This furnishes 
the 5 per cent, iodoform gauze ; if 10 per cent, gauze is 
desired, the quantity of iodoform should be doubled. 
When the gauze is thoroughly saturated, it should be of a 
uniform yellow color. It should then be thoroughly 
wrung out with sterilized hands to remove the alcohol, 
and packed in sterilized jars with tight-fitting cover.-. 

Iodoform gauze may also be prepared by saturating 
sterilized gauze with a mixture of ether and iodoform, 
and then allowing the ether to evaporate, the iodoform 
being distributed evenly through the gauze. 

Carbolized Gauze. — In preparing carbolized gauze, 
cheese-cloth which has previously been boiled and dried 
i- soaked for a few hour- in the following solution : resin, 
16 ounces ; alcohol, 5 pints : castor oil, 24 ounces ; carbolic 
acid, 12 ounces. The gauze i- removed from this solution 
and passed through a sterilized clothes-wringer, and is 
then cut into pieces from four to six yards in length, 
which are folded and packed in air-tight jars for use. 

Improvised Aseptic or Antiseptic Dressings. — 
Aseptic dressings in cases of emergency may be impro- 
vised, where the ordinary gauze dressing- cannot be ob- 
tained, by tearing muslin or mosquito-netting into pieces 
half a yard square and placing them in boiling water for 
a few minutes ; they are then removed, the excess of moist- 
ure is wrung out, and they are applied to the wound. 

If it is desirable, they may be used as antiseptic dress- 
ings by soaking them for a few minutes in a 1 :1000 or 
1:2000 bichloride solution, or in a 5 per cent, carbolic 
solution. This dressing will keep the wound aseptic until 
a more elaborate dressing can be obtained. 

Sterilized Bandages. — Sterilized bandages are pre- 
pared by tearing or cutting gauze into strips from two and 
a half to three inches in width, and forming these strips 
into rollers, which are sterilized by steam or dry heat. 
They should be used soon after being prepared, or. if kept 
for any time, should be resterilized before being used. 

Bichloride Cotton. — This material is prepared by 



318 ASEPSIS AND ANTISEPSIS. 

soaking absorbent cotton in a 1 : 1000 bichloride solution 
for twenty-four hours, and allowing it to dry, or it may 
be dried in a hot oven ; when dry, it is packed in jars or 
in air-tight boxes. Several layers of bichloride cotton 
are usually applied over the gauze dressing, as its great 
absorbing power and elasticity make it, when properly 
prepared, a most valuable dressing. Borated, carbolized, 
and salicylated cotton, prepared in the same manner, are 
also frequently employed for similar purposes. 

Sterilized * Cotton. — Sterilized cotton is prepared by 
placing absorbent cotton, enclosed in perforated metal 
cans, in a steam sterilizer and allowing it to remain for 
half an hour under ten pounds pressure. It is used for 
the same purposes in dressings as the bichloride cotton. 

Moist Sterilized Gauze Dressings. — Moist sterilized 
gauze dressings may be prepared by subjecting gauze 
which has been boiled in soda solution to the action of 
boiling water or of steam for thirty minutes. Gauze thus 
treated should be used as soon as prepared. 

Sterilized Gauze. — This is prepared by cutting pieces 
of gauze the desired size, wrapping them in a towel, 
and placing them in wire baskets ; or the gauze may be 
placed in cylindrical tin boxes, 3 inches in diameter 
and 8 inches in height, with perforated metal covers, 
covering the gauze at each end with a layer of cotton 
before putting on the covers. The gauze is next placed 
in a steam sterilizer and subjected to ten pounds pressure 
of live steam for half an hour. The steam is then shut 
off from the sterilizer and allowed to circulate in the 
jacket of the apparatus without pressure for half an hour, 
to dry the dressings. If the gauze has been sterilized in 
metal cases, it may be kept for some time and still remain 
sterile. Cotton may be sterilized in the same manner. 

Dry Sterilized' Gauze Dressings. — Dry sterilized 
gauze dressings are prepared by cutting gauze into proper 
lengths and packing it loosely in wire cages or perforated 
metal cans, which are next placed in a dry sterilizing- 
oven for several hours, and upon removal it is placed in 
air-tight jars or metal boxes. In using sterilized gauze 



MATERIALS USED IN ASEPTIC OPERATIONS. 319 



dressings, it is safer to have the dressings freshly steril- 
ized immediately before each operation. A convenient 
form of sterilizing-oven is shown in Fig. 238. Towels 
and operating-gowns may be sterilized in the same oven. 




Hot-air sterilizer. 

Surgical Operating-bag. — For operations in private 
practice, the surgeon will find it convenient to have a bag 
or kit containing gauze dressings, bichloride pellets, car- 
bolic acid, alcohol, turpentine, ligatures, sutures, needles, 
syringes, a metal tray in which instruments may be boiled, 
a nest of small agate-ware basins, sponges, gauze pads, a 
sheet of rubber cloth, drainage-tubes, and operating- 
gown. These can all be packed in a comparatively small 
space, and when the surgeon is called upon to perform any 
special operation at short notice the instruments required 



320 ASEPSIS AND ANTISEPSIS: 

may be selected, wrapped in a Canton -flannel scroll, and 
placed in the bag. Much time will be saved by having 
the materials required in operations always in readiness. 



METHODS AND DRESSINGS EMPLOYED TO SECURE 
ASEPSIS IN THE TREATMENT OF WOUNDS. 

To prevent infection of wounds, the various chemical 
sterilizers and dressings are employed in different ways, 
and the principal types of dressings are as follows : 

Method by Simple Drying. — This method is employed 
in small and not very deep wounds. The edges having 
been brought together by sutures, the surface of the 
wound is dusted with powdered iodoform, the serum and 
blood forming with this, as it dries, a scab, which protects 
the wound from infection from without; repair taking 
place promptly under this scab. Treves employs this 
method of dressing in compound fractures. A pledget 
of gauze saturated with iodoform-collodion or tr. benzoin, 
■5J ; collodion, 3vij, may be employed instead of iodoform. 
Dry sterilized gauze and cotton dressings may also be 
employed in this method of dressing. 

Method by Drying and Chemical Sterilization. — 
The object of this method of dressing is to provide a 
means of sterilizing the blood or serum which escapes 
from the wound, and at the same time to insure the ster- 
ilization of the air coming in contact with the discharges 
from the wound. It is employed in large or deep wounds, 
where there is always more or less escape of blood or 
serum, and is accomplished by applying a number of 
layers of sublimate or iodoform-gauze and sublimated 
cotton over the wound. Evaporation not being interfered 
with, the whole dressing becomes hardened, and the wound 
is surrounded by a large antiseptic crust made up of the 
dressing and serum or blood. 

Moist Dressings. — In this method of dressing, the 
wound is covered by layers of moist antiseptic gauze, 
which are kept moist and evaporation prevented by apply- 



PREPARATION OF THE PATIENT. 321 

ing over them some impervious material, such as mackin- 
tosh or rubber-tissue. 

Modified Moist Dressing. — In using this method, the 
wound itself is covered by a piece of protective or 
rubber-tissue ; over this is placed the sublimated or iodo- 
form-gauze dressing and some layers of bichloride cotton. 
In this way the wound itself is kept in a moist condition 
favoring particularly the organization of blood-clots ; the 
external dressings become dry as the discharges which 
have escaped into them evaporate, forming an antiseptic 
crust or covering over the wound. 

Preparation for Aseptic Operation. 

Preparation of Room. — In hospital practice, suitable 
operating-rooms are provided; in private practice, how- 
ever, the surgeon is often called upon to select a room 
and give directions as to its preparation. A well-lighted 
room should always be selected, and all unnecessary 
articles of furniture, such as ornaments, pictures, and 
curtains, should be removed. The carpet should be 
taken up and the floor scrubbed. A few small tables 
and a large wooden table should be placed in the room, 
having previously been dusted and wiped off with a 
bichloride solution. All preparations should be made, 
if possible, upon the day before the operation, as the stir- 
ring up of dust incidental to the change in furniture in 
cleaning the room on the day of operation immediately 
before the time set, is more dangerous than no cleaning 
of the room whatever, since the principal contamination 
of the wound is likely to come from germs contained in 
the dust. In case of emergency, the floor may be well 
moistened by sprinkling with water to lay the dust. The 
preparation of the room is not, in my judgment, a matter 
that affects the results of operations as much as does the 
exercise of great care in regard to aseptic details of the 
operation itself. 

Preparation of the Patient. — The skin always con- 
tains micro-organisms, which develop upon it and are 

21 



322 ASEPSIS AND ANTISEPSIS. 

constantly being deposited upon it from the air. We 
can scarcely hope to obtain absolute sterilization of the 
skin under these circumstances, but by careful prepara- 
tion seek to obtain that relative sterility which enables 
us to obtain primary union. The patient should be given 
a general bath the night before the operation, and the 
skin surrounding the site of operation should be thor- 
oughly scrubbed with a brush and soap and water ; or a 
soap poultice may be applied to the part for a few hours 
before the final sterilization with alcohol and bichloride 
is made. In scrubbing the skin a soft brush should be 
used, since too forcible scrubbing may cause irritation or 
dermatitis. After this scrubbing has been continued for 
a few minutes the skin is washed with alcohol and ether, 
then douched with sterilized water, and there should be 
applied to the surface a folded towel or gauze dressing 
saturated with a 1 : 1000 bichloride solution ; or if a moist 
dressing is uncomfortable to the patient, a few layers of 
sterilized gauze should be placed over the surface and held 
in place by a bandage. A similar washing and prepara- 
tion of the seat of operation should be made the next 
morning, a few hours before the time fixed for operation. 

The skin may also be sterilized by formalin. It should 
first be scrubbed thoroughly with soap and water, and then 
a few layers of gauze saturated with a 1 per cent, solution 
of formalin should be laid over it and covered by an im- 
permeable dressing. This solution should be kept in con- 
tact with the skin for twenty-four or thirty-six hours, the 
compress being changed every twelve hours. 

It is well to remember that regions of the body which 
contain hair and numerous sweat-glands, such as the axilla, 
navel, scrotum, groin, and the creases about the joints, are 
those in which micro-organisms grow with the greatest 
activity. All the surrounding hair should be shaved off; 
and if the operation be upon the skull, it is well to shave 
the scalp completely. 

Sterilization of the Feet. — There is usually present 
upon the feet a large amount of thickened epidermis, 
which renders their sterilization difficult. The feet should 



STERILIZATION OF THE STOMACH. 323 

be washed thoroughly with soap and water and scrubbed 
vigorously with a brush ; or a soap poultice should 
be applied to the whole surface of the feet for some hours 
and held in position by a bandage. A moist dressing 
favors separation of the superficial layers of the epi- 
dermis, and after it has been worn for a few hours it is 
possible to remove a large amount of the latter by the use 
of the brush. After having been washed thoroughly with 
a 1 : 1000 bichloride solution they should be wrapped in a 
towel or a few layers of gauze saturated with bichloride of 
mercury solution, 1 :1000. 

Sterilization of the Vagina. — The vagina and external 
genitals require great care in their sterilization. Accord- 
ing to Schimmelbusch, the best method of sterilizing the 
vagina is to dilate it fully with a speculum, and to scrub it 
thoroughly with pads of gauze saturated with green soap 
and water, and after this cleansing, to irrigate it with a 
1 : 2000 bichloride solution or a 1 per cent, solution of 
kreolin. 

Sterilization of the Bladder and Urethra. — It is 
impossible to sterilize completely the mucous membrane 
of the bladder. The bladder should be emptied by cath- 
eter and filled with sterile water or normal salt solution ; 
this procedure should be repeated several times. The best 
means we have at our disposal at the present time of steril- 
izing the mucous membrane of the bladder consists in irri- 
gating the organ frequently with a 10 grain to the ounce 
solution of boric acid in boiled water. In operations upon 
the urethra the same care should be taken to render the 
urethra sterile by free irrigation with normal salt solution 
or boric acid solution. 

Sterilization of the Stomach. — The stomach should 
be sterilized by thorough lavage with normal salt solution 
or boric acid solution. This is important, not only in op- 
erations upon the stomach itself, but also in operations 
upon the pharynx, to diminish the risk of infection by 
vomited matter. In cases of intestinal obstruction with 
vomiting, lavage of the stomach should always be em- 
ployed before operation. 



324 ASEPSIS AND ANTISEPSTS. 

Sterilization of the Rectum. — When an operation is 
to be performed upon the anus and rectum, the patient 
should be given a purgative and an enema some hours be- 
fore the operation, to remove any fecal matter which may 
be in the rectum. The region of the anus should be dis- 
infected with soap and water and thoroughly scrubbed, and 
after the patient has been anaesthetized the sphincter should 
be well stretched and the rectum irrigated with a boric 
acid solution. A tampon of sterilized gauze, with a string 
attached, should be packed into the rectum above the seat 
of operation, to prevent the wound from becoming soiled 
with feces during the operation. The tampon can be re- 
moved by means of the string after the operation has been 
completed. 

Sterilization of the Scalp. — Great care should be ob- 
served in sterilizing the scalp before operations on the 
scalp or brain, as the scalp is often covered by dense 
masses of epidermis. The entire scalp should be shaved 
and a soap poultice applied for twelve hours, or the appli- 
cation of sweet oil for twenty-four hours before the use of 
the soap poultice may be of use in softening the epidermis. 
It should be rubbed thoroughly with soap and water, and 
finally with a 1 :1000 bichloride solution. 

Sterilization of the Mouth and Nasal Cavities. — To 
render the mouth as far as possible sterile, the teeth should 
be thoroughly brushed with tooth-powder and the cavity 
of the mouth frequently rinsed with a solution of peroxide 
of hydrogen, 1 part to 6 parts of water, or with a satu- 
rated solution of boric acid. The nasal cavities and the 
post-nasal region should be sterilized by spraying them 
with the same solution. 

Sterilization of the Hands. — The difficulty of com- 
pletely sterilizing the hands has been shown by bacterio- 
logical tests, for it has been demonstrated that after great 
care in the process complete sterility could be obtained 
only in about 95 per cent, of the tests. The hands 
of the surgeon, unless properly sterilized, may be the 
most efficient agents in producing infection of the wound; 
the region of the finger-nails and the inter digital folds are 



STERILIZATION OF THE HANDS. 325 

locations where germs are particularly abundant. The 
hands and forearms of the surgeon, assistants, and nurses 
who are to take part in the operation, may be sterilized 
by first rubbing them with spirit of turpentine, and then 
thoroughly scrubbing them with Castile soap and water, 
using a nail-brush freely. Care should be taken that the 
brush is sterilized. This scrubbing should be employed 
for several minutes; the hands are then rinsed to remove 
the soap, and are soaked for two minutes in a 1 : 1000 
bichloride of mercury solution. If turpentine has not been 
employed before washing with the soap, strong alcohol or 
ether should be rubbed well over the hands before they 
are immersed in the bichloride solution. When the hands 
have been sterilized they should not be brought in contact 
with anything that is not sterile. 

Harrington's Method. — Harrington after washing the 
hands thoroughly with green soap immerses them in the 
following solution for a few minutes : alcohol (94 per cent.) 
640 c.c, hydrochloric acid 60 c.c, water 300 c.c, corrosive 
sublimate 0.8 grammes. This solution has been found to 
be a most efficient sterilizing agent. 

Permanganate of Potassium and Oxalic Acid. — A method 
of sterilizing the hands which is very satisfactory is that 
employed by Kelly, which consists in washing the hands 
and forearms with soap for ten minutes, and then soaking 
them for a few minutes in a warm saturated solution of 
permanganate of potassium, which stains them a deep 
mahogany color ; they are then washed in a warm satu- 
rated solution of oxalic acid until all the permanganate 
stain is removed, and should next be washed in sterilized 
water to remove the oxalic acid which may adhere to the 
skin. 

Chloride of Lime and Carbonate of Sodium. — Weir 
recommends the following method of sterilizing the 
hands. After washing them with green soap, put a table- 
spoonful of commercial chloride of lime and an equal 
amount of carbonate of sodium (washing-soda) in the 
hand, with enough water to make a paste. Rub this into 
a thick cream, which should be rubbed into the hands 



326 ASEPSIS AND ANTISEPSIS. 

until the grains of lime disappear and the skin feels cool. 
The hands are then rinsed in sterile water. This method 
of sterilization of the hands has, in my experience, been 
most satisfactory. 

Sterilization of Instruments. — The sterilization of 
instruments may be accomplished by dry or moist heat ; 
they should be placed in a hot-air sterilizer or baked for 
twenty minutes in a hot oven. Sterilization of instru- 
ments by dry heat or baking is not often employed, as it 
is apt to spoil the temper of the steel. Instruments may 
be sterilized by the method suggested by Schimmelbusch, 
now almost universally employed, which consists in boil- 
ing them for fifteen minutes in water to which a table- 
spoonful of washing-soda (carbonate of sodium) has been 
added for each quart of water ; this prevents the rusting 
of the instruments, and also makes the water a better sol- 
vent for any fatty matter which may be upon the instru- 
ments, thus increasing the sterilizing effect of the heat. 
If wooden-handled instruments are used, which would 
be injured by boiling, they should first be thoroughly 
scrubbed with soap and water and a brush, and after 
having been rinsed in sterilized water they should be placed 
in a tray and covered with 1 : 20 watery solution of car- 
bolic acid, and allowed to remain in this solution for at 
least half an hour; before being used they should be 
transferred to a bath of sterilized water, which will prevent 
the benumbing effect of the carbolic solution upon the 
surgeon's hands. 

Instruments may also be sterilized by formalin : the 
latter is generated by heating pastilles of paraform with 
Schering's formalin lamp. The instruments are placed 
in racks in a metal case, and by burning from 10 to 15 
grains of paraform the instruments may be rendered 
sterile in fifteen minutes. 

Instruments which fall upon the floor or come in con- 
tact with the clothing of the surgeon or of the patient 
during the operation, should again be sterilized before 
being brought in contact with the wound. 

Sterilization of Catheters and Bougies. — These, if 



STERILIZATION OF INSTRUMENTS. 327 

made of metal or glass, may be sterilized by boiling for 
ten minutes in a 1 per cent, solution of sodium carbonate. 
If constructed of rubber or gum, prolonged boiling 
destroys them ; these may, however, be sterilized by first 
washing them with soap and water and then placing them 
for fifteen minutes in a 1 per cent, solution of sodium 
carbonate, heated nearly to the boiling-point ; they are 
next placed in a 1 : 1000 bichloride solution until required. 
They should, on being removed from this solution for use, 
be soaked thoroughly in hot sterile water to remove all 
the bichloride solution. Rubber catheters may also be 
sterilized by soaking them for an hour in a 2 per cent, 
solution of formalin, or by placing them in an air-tight 
metallic case or glass jar containing pastilles or paraform. 
They can be kept indefinitely in such a receptacle, and 
when removed for use should be washed in sterilized 
water. For lubricating catheters and bougies, oily mate- 
rials should be avoided, and sterilized glycerin or lubri- 
chondrin, both of which are soluble in water, should be 
employed. 

Rubber Gloves. — These gloves are now extensively 
employed in operative work, and the results following 
their use have been most satisfactory. They are made of 
very thin rubber, so that there is little interference with 
tactile sensation, and from their elasticity they fit the 
hands accurately. They can be rendered absolutely ster- 
ile, and as they are impervious to moisture there is no 
risk of wound infection if the hand is not completely 
sterilized unless the gloves have been torn or punctured. 
To avoid this possibility of infection the hands should be 
sterilized as completely as possible before they are applied. 
They may be sterilized by first washing them with soap 
and water, and then immersing them for twenty-four hours 
in a 1 : 1000 bichloride solution. The better method of 
sterilization, however, consists in wrapping them in a 
towel and boiling them for ten minutes in a 1 per cent, 
solution of carbonate of sodium. They are usually 
applied by filling them with sterilized water or salt solu- 
tion, and then introducing the hand ; some operators 



328 ASEPSIS AND ANTISEPSIS. 

prefer to apply them dry to the hand, using a dry sterilized 
powder, such as starch or soapstone. If properly cared 
for, a pair of gloves will withstand a number of steriliza- 
tions. A freshly sterilized pair of gloves should be used 
for each operation. 

Cotton or silk gloves, which have been sterilized by 
boiling or by dry heat, have been recommended by 
Mikulicz and other surgeons, to be worn during opera- 
tions. Experiments, however, have shown that cotton or 
silk gloves are not as safe as those made of rubber. 

Clothing of Surgeon and Assistants. — The surgeon 
and his assistants should wear sterilized linen or muslin 
suits, or be provided with gowns with sleeves reaching to 
the elbows, for the protection both of the patient and of 
their clothing. The operating-gown should be made of 
muslin or linen, which can easily be sterilized by boiling 
or heat ; a variety of linen known as butchers' linen is very 
serviceable for this purpose. As a matter of additional 
precaution, many surgeons and their assistants wear dur- 
ing the operation closely fitting skull-caps of linen or gauze, 
and wear over the nose and mouth a mask or a pad com- 
posed of a number of layers of sterilized gauze to prevent 
infection of the wound by the expired air. The surgeon 
and assistants will often find it convenient to wear under 
their linen gowns India-rubber aprons, to prevent soil- 
ing of the clothing by blood or solutions. The nurses 
should wear sterilized linen or muslin operating-gowns and 
dresses of washable goods. An operating-apron may be im- 
provised from a clean sheet folded so as to be one and a half 
yards in width and from five to six feet in length, by turning 
in about ten inches of one end of the sheet over the upper 
part of the chest and placing a strip of bandage in this 
fold, which should be secured around the neck, and tying 
a second strip of bandage over the sheet at the waist. 

Details of an Aseptic Operation. — The patient being 
prepared for operation as described, and having been 
anaesthetized, is placed upon the operating-table, the sur- 
geon, assistants, and nurses also being prepared for the opera- 
tion as previously described. If the operation be one upon 



DETAILS OF AX ASEPTIC OPEEATIOS. - 

face, neck, or chest, it is well, before the dressi gs 

ring the seat : >peration are removed, to cover the 

patient's hair with a towel or handkerchief-bandage* made 

eral layers of sterilised or bichloride gauze. The 

- f the patient's body which it is n of 2ss ary to 

se in the operation should red with a woollen 

blanket, and this covered with a sterilized she-:, 
sargeons prefer to have the patient wear a nterSk 
which is ripped or cat t - rt 1 e operated 

upon. The region of the wound and the operaring-table 
are next protected with sterilized to we'- I rhs. The 

surgeon having ae gned the assist ts and nurses their 
duties, the dress _ - removed from the pan to be 
ated upon, and the operation is begun. Hemorrhage is 
controlled by the use of haem - - and steril- 

_ - ire employe! to keep the wound 

from blood. When the operation is completed, the 
vessels are li gated, the haemostatic - are ren. 

and the wound is dried with gauze pledgets. If, for 
any reason, t: - _ m deems it advisable to irrigate 
the wound, it may be done with hot -terilized water or 
with sterilize! salt solution. If the surgeon decides that 
drainage is n<:-t necessary, the ]\e wound 

may then be brought together with buried sutur - 
catgut or silk, and the edges of the superficial wound next 
approximated by sutures k>1 catgut, silk, or silkworm-gut. 
If the surgeon decides to use drain g losing the 

wound a few strands of catgut, a strip of sterilize! gauze. 
a tent of rubber-tissue, or a rubber or glass drainage-tube 
is introduced into the deepest portion of the wound and 
brought out at its most dependent part. The wound is 
then dressed with a number of Lx.se n sses : sterilized 
gauze placed - as 1 the wound and extend beyond 

it in all directions, and these arc I by a number of 

layers of sterilize:! gauze, and the dressings are held in 
place by a gauze bandage. The bandage should be applied 
ttou at the elges of the dressing, and 
thus make the occlusion of air from the wound as complete 

-sible. Over the gauze Iressi g are placed a few 



330 ASEPSTS AND ANTISEPSIS. 

layers of sterilized cotton, extending on all sides well beyond 
the gauze, and the dressings are held in place by a steril- 
ized gauze bandage. The dressings should be voluminous ; 
it is always a mistake to apply scanty dressings. In 
redressing the wound the same care should be exercised 
as regards asepsis as was observed at the primary 
dressing. 

Details of an Antiseptic Operation. — The region of 
the wound being previously sterilized and the patient 
being anaesthetized and placed upon the table, the cloth- 
ing is so arranged as to expose freely the part to be oper- 
ated upon ; the clothing or the skin surrounding this region 
is next covered with towels wet with a 1 : 1000 bichloride 
solution. If any considerable surface of the patient's body 
is covered by these towels, to avoid chilling the surface and 
adding to the shock which naturally follows the operation, 
they should be wrung out in a hot bichloride solution, and 
should be replaced as they become cold by hot towels pre- 
pared in the same manner. The patient being ready for 
operation, the surgeon should assign the assistants and 
nurses their duties, and having previously sterilized his 
hands and forearms, and again immersed them in the bi- 
chloride solution, the operation is begun. 

During the operation the wound is irrigated frequently 
with a 1 : 2000 to 1 : 4000 bichloride solution, which may 
be applied to the wound by means of a syringe or irrigat- 
ing apparatus (Fig. 239), and the hands of the surgeon 
and assistants should also be washed in this solution at 
not too long intervals. In prolonged operations, or in 
those in which a large wound is made, it is especially 
important that the irrigating solutions should be used as 
warm as can comfortably be borne by the hands of the 
surgeon ; warm solutions, it has been shown by recent 
investigations, possess a greater germicidal power than 
those of the same strength when used cold, and they also 
possess the advantage of preventing chilling of the patient, 
and thus diminish the shock of the operation. 

Hemorrhage during the operation is controlled by the 
use of haemostatic forceps, which are applied to the bleed- 



DETAILS OF AN ANTISEPTIC OPERATION 331 

ing vessels, or the vessels may be ligatured as they are 
divided. After the operation has been completed, and all 
hemorrhage has been controlled, the wound is thoroughly 
irrigated with a 1 : 4000 to 1 : 2000 bichloride solution. 

The next step is to provide for drainage ; this may be 
disregarded in small, superficial wounds, but in a wound 
of considerable size or depth it is safer to provide free 
drainage. This is accomplished by the use of perforated 
rubber drainage-tubes, or a number of strands of catgut, 
or strips of iodoform or bichloride gauze. 

Fig. 239. 




Irrigating apparatus. (Esmarch.) 

The rubber tube may be laid in the wound, the ends 
being allowed to extend from the extremities of the wound, 
or it may be so introduced that one end of the tube rests 
in the deepest part of the wound and the other extremity 
is brought out of the wound at its most dependent portion ; 
in large or irregularly shaped wounds a number of tubes 
may be required to secure free drainage. The ends of the 
drainage-tubes are transfixed with safety-pins which have 
been sterilized, and should next be cut off close to the pins 
so as to be as nearly as possible flush with the skin. 



332 ASEPSIS AND ANTISEPSIS. 

The wound being closed by sutures, a final irrigation of 
its deepest parts should be made, by injecting a stream of 
bichloride solution, 1 : 4000 to 1 : 2000, into the end of the 
drainage-tube. The external surface of the wound, and 
the skin for some distance surrounding it, should next be 
washed with a 1 : 4000 to 1 : 2000 bichloride solution, 
and a piece of protective, a little longer and wider than 
the wound, is dipped in a bichloride or carbolic solution 
and placed over it. The use of protective over the 
wound is important only if it is desired to keep the 
wound moist, in order to obtain organization of the blood- 
clot, otherwise it need not be employed. Over this is 
laid the deep dressing, which consists of a pad of bichlo- 
ride gauze from eight to sixteen layers in thickness, and 
large enough to overlap the wound two or three inches 
in all directions. This should be dipped in a 1 : 4000 to 
1 : 2000 bichloride solution, and wrung out as dry as pos- 
sible before being applied. The superficial gauze-dressing 
is next applied, and consists of sixteen layers of gauze, 
which should be large enough to extend from three to six 
inches beyond the wound in all directions ; this gauze is 
applied dry. Over the superficial gauze-dressing there is 
next applied a number of layers of bichloride cotton, 
so arranged as to extend a little beyond the margin of 
the superficial gauze-dressing. These dressings are next 
secured in position by the application of a gauze-bandage, 
which is prevented from slipping by the introduction of a 
few safety-pins. Iodoform, carbolized, or any other variety 
of medicated gauze, may be used in place of the bichloride 
gauze. 

In this method of dressing, no mackintosh or rubber- 
tissue is employed outside of the superficial gauze-dress- 
ing ; the discharges of the wound are disseminated through 
the dressing and become dry by evaporation, and the 
dressing forms an antiseptic scab which covers and sur- 
rounds the wound. 

Moist Method of Dressing. — If, for any reason, it is 
desired to adopt the moist method of dressing, a piece of 
mackintosh or rubber-tissue larger than the superficial 



REDRESSIXGS OF THE WOUND. 333 

gauze-dressing is placed over it, and over this are placed 
a few layers of bichloride cotton, care being taken to see 
that the layers of cotton overlap the mackintosh or rubber- 
tissue by a few inches ; the application of an antiseptic 
ganze-bandage then completes the dressing. On removal 
of this dressing the gauze will generally be found to be 
soaked with the discharges from the wound, and in a 
moist condition. The disadvantage of this variety of 
dressing is that there is apt to be more irritation of the 
skin set up by the bichloride gauze when kept moist than 
when applied in the manner of a dry dressing. 

Redressings of the Wound.— The redressing of a 
wound which remains aseptic need not be made for some 
days; if the temperature remains normal or a little above 
this point, and the patient exhibits no unfavorable con- 
stitutional symptoms, and the dressing is comfortable to 
the patient, it need not be disturbed for a week or ten 
days ; at the expiration of this time it is well to examine 
the wound and to remove the drainage-tube if drainage 
has been used, and to remove a portion or all of the 
sutures if the superficial parts of the wound are firmly 
healed 

In redressing a wound in which the antiseptic method 
was employed, at the end of a week or ten days, to pre- 
vent any possible infection, as much care should be 
exercised as in the original dressing of the wound. The 
patient's clothes should be removed so as freely to expose 
the dressing, and a rubber cloth should be placed under 
the patient so as to protect the bed, and the clothing and 
skin in the region of the wound should be protected by 
towels wrung out in a 1 : 1000 bichloride solution. The 
surgeon should wash his hands and immerse them in a 
1 : 1000 bichloride solution before removing the dressings. 
The bandage retaining the dressing should be divided with 
bandage-scissors and the gauze removed layer by layer, 
and when the deep dressing is removed care should be 
taken that the drainage-tubes are not pulled upon if they 
are adherent to the dressing ; the protective should next 
be removed and the surface of the wound irrigated with a 



334 ASEPSIS AND ANTISEPSIS. 

1 : 2000 bichloride solution. If the wound is found aseptic, 
the drainage-tube may be removed, and the superficial 
wound be irrigated with bichloride solution. If the wound 
is healed, the sutures may be removed at this dressing ; but 
if the wound has been an extensive or deep one, it may be 
well to remove only a portion of the sutures ; if catgut 
sutures have been employed, they need not be removed. 
The surface of the wound is next irrigated with a 1 : 2000 
bichloride solution, and deep and superficial gauze-dress- 
ings are applied as previously described, and covered 
with layers of bichloride cotton, and the whole dressing 
is secured by the application of an antiseptic bandage. 
If the wound remains aseptic, the dressings need not be 
changed for a week or ten days, and at this time the 
wound will usually be found healed, so that further dress- 
ings are not required. 

In the redressing of a wound in which the aseptic method 
was employed, the use of germicidal solutions is omitted, 
and the wound is redressed with sterilized gauze and cotton. 
If, however, the wound is not running the typical course 
of an aseptic wound, constitutional symptoms will be de- 
veloped, as evidenced by a rise in the temperature and pulse- 
rate and other constitutional disturbances. In this event 
the wound should be redressed as soon as possible, and if 
the cause of the disturbance can be found, it should be 
removed ; for instance, hemorrhage may have taken place 
into the wound, and the blood not being able to escape 
through the drainage-tubes may have caused so much dis- 
tention of the wound that the vitality of the skin cover- 
ing the wound is threatened, or the sutures may be found 
to be causing irritation, or suppuration may be present. 

If, on exposure of the wound, it is found that it is dis- 
tended with blood-clots, and that blood is escaping from 
the wound, the sutures should be removed, the clots 
turned out, and the bleeding vessel or vessels sought for 
and ligatured, and the wound, after a thorough irrigation 
with 1 : 4000 to 1 : 2000 bichloride solution, should be 
drained and closed with sutures, and dressed as previously 
described. 



TREATMENT OF INFECTED WOUNDS. 335 

If, however, on exposure of the site of the operation, 
and upon the removal of a portion or all of the sutures* 
the wound is found distended with a blood-clot, and no 
evidence of hemorrhage at the time exists, or of suppura- 
tion in the wound, the clot may be allowed to remain in 
place, and the wound should be redressed as in the original 
dressing, trusting to the organization of the blood-clot if 
it has remained aseptic. If the patient's condition im- 
proves after the dressing, and the temperature and pulse- 
rate become normal, it is an indication that the wound is 
still aseptic, and it need not be redressed for some days. 

If, on the other hand, examination of the wound shows 
that the drainage is insufficient, or that the drainage- 
tubes are occluded by blood-clots, these should be removed 
by washing out the tubes with a 1 : 4000 to 1 : 2000 bi- 
chloride solution by means of a syringe, and introducing 
additional drainage-tubes, if it is deemed necessary ; the 
wound should then be redressed. 

When it is found on examination of the wound that 
suppuration is present, it should thoroughly be irrigated 
through the drainage-tubes with a 1 : 2000 bichloride 
solution, and after thorough irrigation it should be 
redressed, and, if the constitutional symptoms improve, it 
may be assumed that the wound has been rendered aseptic. 

Aseptic or Antiseptic Treatment of Infected 
Wounds. — It often happens that the surgeon is called 
upon to treat a wound which is septic when it comes 
under his care, as evidenced by the inflamed state of the 
wound, inflammation of the lymphatic vessels and skin, 
foul discharges and sloughing of the tissues, and the 
coexistent constitutional symptoms of sepsis. In such a 
case it would at first sight appear that the surgeon or his 
assistants could not introduce any material of infection 
worse than that which already existed in the wound, but 
he should bear in mind the fact that it is possible to intro- 
duce a new form of infection in addition to that already 
existing. With this possibility in view, he should observe 
the same precautions as regards the sterilization of his 
hands, the region of the wound,, the instruments, and 



336 ASEPSTS AND ANTISEPSIS. 

dressing, as he would employ in treating a perfectly fresh 
wound. 

Recent investigations, however, have shown that the 
germs in abscesses are to a great extent dead, and that 
the pus-formation is largely due to the irritation caused 
by their products. In view of these facts, it would seem 
that the most important part of the treatment of infected 
wounds is thorough drainage. It is a question whether 
the micro-organisms in the walls of infected cavities or 
sinuses can be destroyed by antiseptic irrigation. Some 
surgeons recommend active treatment, both mechanically 
and by the use of germicidal solutions, while others are 
satisfied simply to secure free drainage ; and if irrigation 
is necessary, they do not employ strong germicidal fluids 
but use simply sterilized water or sterilized salt solution. 
I prefer to employ the antiseptic method in dealing with 
infected wounds, and can recommend the following plan. 
The skin surrounding the wound for some distance should 
be wiped over with spirit of turpentine and carefully 
scrubbed with soap and water, and should next be washed 
with a 1 : 1000 bichloride solution ; the wound itself 
should next be washed with peroxide of hydrogen and a 
1 : 1000 bichloride solution. AYith forceps and curette, 
any dirt or sloughing tissue should be removed ; then the 
wound again washed with peroxide of hydrogen and 
douched with a 1 : 2000 bichloride solution. The wound 
should then be dried with gauze pledgets and dusted with 
iodoform, and loosely packed with strips of iodoform 
gauze. If from the appearance of the tissues the surgeon 
has reason to think that the infection has passed beyond 
the reach of the curette or scissors, he may swab over the 
surface of the wound with a solution of chloride of 
zinc, 30 grains to the ounce of water, or a 2 per cent, solu- 
tion of formalin. Pure carbolic acid may be used, and is 
recommended by some surgeons, for the same purpose as 
chloride of zinc, but the toxic action of carbolic acid causes 
its employment to be attended with some danger. Toxic 
effects and too extensive cauterization may be prevented 
by washing the part with absolute alcohol. Free drainage 



TREATMENT OE INFECTED WOUNDS. 337 

being secured by the introduction of a few strips of iodo- 
form gauze, the wound is dressed with a voluminous dress- 
ing of bichloride gauze and bichloride cotton. No at- 
tempt, as a rule, should be made to bring together the edges 
of such a wound by the introduction of sutures. In the 
dressing of infected wounds, when the discharges are ropy 
or viscid they are not well absorbed by dry dressings, and 
in this class of wounds it is, therefore, often of advantage 
to employ moist antiseptic dressings. By this method of 
treatment it is often possible to convert a septic wound into 
an aseptic one, and have rapid improvement follow both in 
the local condition of the wound and in the constitutional 
condition of the patient. 

22 



PAET IV. 

FRACTURES 



In the following section the author has endeavored to 
confine himself simply to a description of the varieties of 
fracture and to their dressing and treatment, and he has 
tried as far as possible to avoid the multiplication of 
dressings, being satisfied to describe a few of the methods 
of dressing most frequently employed. He has also 
avoided the description of complicated splints and dress- 

_-. by the nse of which in certain fractures m - 
lent results are obtained, but has preferred to recommend 
the employment of simple splints and dressings, which 
can be obtained by physicians practising in districts 
remote from large cities, where the services of an instru- 
ment-maker cannot he obtained to construct special appa- 
ratus for the treatment of the.-e injuries. 



VARIETIES OF FRACTURE. 

Complete Fracture.— Thi^ is a fracture in which the 
line of separation completely traverses the bone, involv- 
ing ts entire thiekne—. 

Incomplete Fracture. — This is a fracture in which 
there i- only a partial separation of the bone-fibre- FL r . 
2-k>). under which name is included partial or u green- 
atick " fracture, in which some of the bone-fibres have 
given way, while the remaining fibres have been bent by 

339 



340 



FRACTURES. 



the force, but have not been broken (Fig. 241). Fissured, 
punctured, indented, and perforating fractures are also 
included in the class of incomplete fractures (Fig. 242). 



Fig. 240. 



Fig. 241. 



Fig. 242. 





mrt 




Incomplete fracture 
of femur. 



Partial or green-stick 
fracture of radius. 



Fissured fracture of the 
humerus. (Gurlt.) 



Subperiosteal Fracture. — This is a fracture in which 
the fibres of the bone are ruptured but the periosteum re- 
mains untorn ; it is seen in children. 

Gunshot Fractures. — The nature of the injury to the 
bone depends upon the density of the latter, and upon the 
size, shape, composition, and velocity of the ball. In gun- 
shot injury of the spongy bones the cancellated structure 
yields to pressure, and the striking energy is not trans- 
mitted in lateral directions, producing explosive effects; 
while in the dense bones, such as the submaxillary bones 



VARIETIES OF FRACTURE. - 341 

or the shafts of the long bones, extensive comminution and 
Assuring are apt to result. In the articular ends of the 
long bones clean perforations are often observed, except 
at close range, when more or less comminution of the can- 
cellated structure may occur. The tissues from the wound 
of entrance to the bone are usually injured only in the 
line of perforation, but those beyond the seat of injury 
are often extensively lacerated and contused, not only by 
the ball, but also by the splinters of bone driven into the 
tissues, and acting as secondary missiles. 

Simple or Closed Fracture. — This is a fracture in 
which there are but two fragments, and the seat of injury 
in the bone does not communicate with the external air by 
a wound in the soft parts. 

Compound or Open Fracture. — This is a fracture in 
which the seat of injury in the bones communicate^ with 
the external air by a wound in the soft parts. 

Comminuted Fracture. — This is a fracture in which 
there are more than two fragments, the lines of fracture 
intercommunicating with each other (Fig. 243). 

Multiple Fracture. — This is a fracture in which a bone 
is the seat of two or more distinct fractures at different 
points, the lines of fracture not necessarily communicating 
with each other. 

Complicated Fracture. — This is a fracture accompanied 
by some serious injury of the parts in the region of the 
fracture — as, for instance, the laceration of important 
bloodvessels or nerves, contusion or laceration of the mus- 
cles, or dislocation of a neighboring joint. 

Impacted Fracture. — this is a fracture in which one 
fragment is driven into and fixed in the other, the impac- 
tion taking place at the time of fracture, or being caused 
by a force subsequently applied (Fig. 244). 

Transverse Fracture. — This is a fracture in which the 
general line of division of the bone is at right angles with 
the long axis of the bone (Fig. 245). Transverse fract- 
ures of the long bones are rarely met with, the line of 
fracture usually being more or less oblique. 

Oblique Fracture" — This is a fracture in which the line 



342 



FRACTURES. 




Fig. 245. 



Comminuted fracture 
of patella. 

Fig. 244. 





Impacted fracture. 



Transverse fracture of 
femur. (Guelt.) 



of separation is oblique to the long axis of the bone. This 
is one of the most common directions of the line of fract- 
ure (Fig. 246). 

Longitudinal Fracture. — This is a fracture in which 
the line of separation runs in the general direction of the 
long axis of the bone (Fig. 247). This form of fracture 
is rare, but is sometimes met with in the long bones as the 
result of gunshot injury. 

Symptoms of Fracture. — The most prominent symp- 
toms of fracture are loss of function, deformity, preter- 
natural mobility, pain, crepitus, and muscular spasm. In 
impacted fractures, crepitus and preternatural mobility are 
absent. 



VARIETIES OF FRACTURE. 
Fig. 246. Fig. 247. 



343 




Oblique fracture of humerus. 

(Stimson.) 



Longitudinal fracture of tibia. 
(Stimson.) 



Deformity. — The deformity or displacement in fractures 
is either angular, transverse, longitudinal, or rotary. 

Examination of Fractures. — In examining a case of 
fracture to locate the nature and seat of the injury, the 
clothing should be removed from the part with as little 
disturbance as possible, and it is better, in most cases, to 
cut or rip the clothing rather than to attempt to remove 
it in the ordinary manner. The surgeon should first 
inspect the injured part, and, where possible, compare it 
with its fellow, as in the case of injuries of the extremities ; 
much valuable information is also derived from the patient 
or his friends as to the manner in which the injury was 
produced. The part should next be carefully examined by 
the surgeon ; if it be one of the extremities which is in- 



344 FRACTURES. 

jured, it should be gently lifted, firm extension being made 
at the same time, the surgeon by his touch and by gentle 
movements seeking to locate the seat of fracture ; and he 
may, by his manipulation, at the same time develop crepitus. 

All manipulations should be made with care, and with 
the greatest gentleness, not only to save the patient from 
pain, but also to prevent the soft parts in the region of the 
fracture from being injured by the rough or sharp frag- 
ments of the bone. Eough handling of fractures may 
increase the muscular spasm by the irritation caused by 
the sharp fragments of the bones, and may also result in 
the injury of important vessels and nerves, and indeed a 
simple fracture may readily be converted into a compound 
one by forcible and injudicious manipulations. 

The sooner the examination is made after fracture has 
occurred the better, for at this time there is less swelling 
in the region of the injury, and the surgeon can locate 
the bony prominences with much more ease, and often 
discover the exact seat of the fracture with the least 
amount of manipulation of the parts. When a case of 
suspected fracture is not subjected to examination for 
several days after reception of the injury, the parts in the 
region of the supposed fracture are often so much swollen 
that it is impossible to accurately locate its seat, and in 
such a case it is often necessary to wait until the swelling 
has subsided before the position of the fracture can be sat- 
isfactorily fixed, the case being treated in the meantime as 
one of fracture. 

Anaesthetics. — These may be employed to relieve the 
patient from pain and to obliterate muscular spasm in the 
examination of fractures. Their employment is often of 
the greatest service in the diagnosis of obscure or compli- 
cated fractures, especially those in the neighborhood of 
joints ; but the surgeon should remember that all manipu- 
lations should be made with the same gentleness as when 
the examination is conducted without anaesthesia, for there 
is the same risk of injury to the surrounding structures by 
the fragments ; this precaution is often neglected when an 
anaesthetic has been given, the surgeon being inclined to 



PROVISIONAL DRESSINGS OF FRACTURES. 345 



Fig. 248. 



handle the parts more roughly than he otherwise would ; 
such practice cannot be too severely condemned. 

X-ray Examination. — This method of examination is 
now very widely employed in fractures. The use of the 
fluoroscope or of a skiagraph taken by the x-rays has 
proved a valuable means of ascertaining the existence, 
location, and nature of the fracture in obscure cases. 

Provisional Dressings of Fractures. — It generally 
happens that fractures occur at localities more or less dis- 
tant from the point where the treatment of the fracture is 
to be conducted, and the transportation of the patient and 
the temporary dressing of the 
fracture are, therefore, matters 
of the first importance. In 
fractures of the upper extremity, 
if the fracture be simple, the 
clothing need not be removed, 
and the arm should be bound 
to the side by some article of 
clothing, or supported in a 
sling made from handkerchiefs 
or the clothing, and the patient 
can usually walk or ride for a 
short distance without much 
injury to the parts in the re- 
gion of the fracture or incon- 
venience to himself. When 
the bones of the lower extremi- 
ties or the trunk are the parts 
involved, the transportation of 
the patient is a matter of more 
difficulty. When the bones of 
the trunk are involved, the 
part should be surrounded by 
a binder firmly pinned or tied, 
made from the clothing or from ' 

towels, or sheets, or other strong materials which are at 
hand. When the bones of the lower extremity are in- 
volved, if the fracture be a simple one the clothing need 
not be removed, and the motion of the fragments should 




Provisional dressing for fracture of 
the leg. (Esmarch.) 



346 FRACTURES. 

be prevented by applying to the sides of the limb, extend- 
ing above and below the seat of fracture, strips of wood, 
shingles, pasteboard, bundles of straw, strips of bark 
taken from trees, or bundles of twigs, these being held 
in place by handkerchiefs or strips torn from the clothing 
(Fig. 248). Umbrellas or canes, or broomsticks, applied 
in the same manner, may be employed, the object of all 
of these dressings being to secure temporary fixation of 
the fragments of bone during the transportation of the 
patient. 

If the fragments are not fixed in some way, but are al- 
lowed to move about during the transportation of the 
patient, much damage may result to the soft parts sur- 
rounding the fractured bones, and simple fractures may 
become compound ones by the bones being forced through 
the skin, the discomfort of the patient at the same time 
being much increased. 

Having applied a dressing to bring about fixation of 
the fragments, the patient should next be placed upon a 
broad board or settee ; if a mattress cannot be obtained, 
the fractured limb should be laid upon a mass of clothing, 
or upon straw, and he should be placed in a wagon or 
carried to the point where the subsequent treatment of 
the fracture is to be conducted. 

Reduction or Setting of Fractures. — This should be 
effected as soon as possible after the occurrence of the 
injury and as soon as the surgeon is prepared to apply the 
dressings to keep the parts in their proper position ; reduc- 
tion at an early period is less painful to the patient, and is 
accomplished with more ease to the surgeon than at a later 
period, when marked inflammation and swelling are present 
at the seat of fracture. Reduction consists in bringing 
the fragments, by manipulation, as nearly as possible in 
their normal position ; this is accomplished by extension 
and manipulation with the hands, care being taken to 
use as little force as possible to attain the object. Very 
little force is required if the surgeon places the part in 
such a position as to relax the muscles which produce the 
displacement ; when this is accomplished, the fragments 



FRACTURE DRESSINGS. 347 

can usually be pressed into position by the fingers without 
the application of considerable force. When the reduc- 
tion of a fracture has been accomplished, the fragments 
are retained in position by the application of various splints 
or dressings which serve to prevent their displacement. 



MATERIALS AND APPLIANCES USED IN THE 
DRESSING OF FRACTURES. 

The Fracture Bed. — Many ingenious forms of beds 
have been devised for the use of patients suffering from 
fractures of the bones of the trunk and lower extremities, 
with the object of permitting the patient to have fecal 
evacuations without disturbing his position ; but a simple 
bedstead provided with a firm hair mattress is usually 
more satisfactory than the complicated form of bed. 

It will be found more convenient in handling the patient 
to use a single bed not over thirty-two or thirty-six inches 
in width, and it is not essential that the mattress be per- 
forated, as a bed-pan can usually be slipped under the 
patient. The use of an ordinary shallow tin pie-plate 
covered with a piece of old muslin to receive the fecal 
evacuations may be substituted for the bed-pan, and will 
be found in many cases more satisfactory, especially in 
the case of children suffering from fracture of the lower 
extremity. 

Splints. — After the reduction or setting of the frag- 
ments in cases of fracture, they are usually retained in 
position until union occurs by the use of splints held in 
position by means of bandages or strips of muslin. Splints 
may be made of wood, or of tin, lead, copper, or wire, 
binders' board, leather, felt, paper, gutta-percha, or plaster- 
of-Paris. 

Wooden Splints. — The simplest splints are made from 
wood — white pine, willow, or poplar being the best mate- 
rial to employ for their construction, being sufficiently 
strong to give fixation to the parts and at the same time 
being light. Splints made from smooth white pine, wil- 



348 FRACTURES. 

low, or poplar boards from one-eighth to one-fourth of an 
inch in thickness may be employed in the form of straight 
or angular splints, and their preparation is a matter of 
little difficulty. 

Wooden splints before being applied to the part should 
be well padded with cotton, oakum, or hair ; and where 
lateral wooden splints are employed in the treatment of 
fractures of the lower extremity it is usual to place band- 
ages or junk bags between the limb and the splint. The 
carved wooden splints which are sold by the instrument- 
makers are not to be recommended, as a rule, for unless 
the surgeon has a large number to select from, it is rare 
that a splint can be obtained to accurately fit any indi- 
vidual case. 

Binders' Board Splints. — Binders' board is an excellent 
material from which to construct splints ; it is first soaked 
in boiling water, and when sufficiently soft is padded with 
cotton or a layer of lint and moulded to the part. It may 
be secured in position by a bandage ; as it becomes dry, it 
hardens and retains the shape into which it was moulded. 

Undressed Leather Splint. — Undressed leather is a good 
material from which to construct splints; it is applied by 
first soaking the leather in boiling water, and after padding 
it with cotton or lint it is moulded to the part and re- 
tained in position by a bandage. 

Felt Splints. — These are made from wool saturated with 
gum shellac and pressed into sheets. This material is pre- 
pared for application to the surface by heating it before a 
fire until it becomes pliable, or by dipping it into boiling 
water. 

Gutta-percha Splints. — These are made from sheets of 
this material from one-sixteenth to one-fifth of an inch in 
thickness, and may often be employed with advantage. 
The splint is prepared for use by immersing it in hot 
water ; when it becomes soft it can be moulded to the sur- 
face. Care should be taken that it is not allowed to become 
too soft by long immersion, as it then cannot be conven- 
iently handled. 

Paper Splints. — These are made from layers of Manila 



FRACTURE DRESSINGS. 349 

paper stiffened with starch, and constitute a very fair 
substitute for some of the varieties of splints previously 
mentioned. 

Plaster-of-Paris, Starch, Chalk and Gum, Silicate of 
Potassium or Sodium Splints. — These may be employed for 
the construction of splints, either movable or immovable, 
in the treatment of fractures : their methods of prepara- 
tion and application are described on page 93 et seq. ; the 
plaster-of-Paris dressing is the 
one which is most generally used Fig. 249. 

at the present time. 

Fracture-box. — This is a form 
of splint used in the treatment f~~ 
of fractures of the lower ex- %^ gemrig 
trernitv, and consists of a board ^ 

eighteen to twenty inches in Fracture-box with movable 

length, with a foot-board firmly 

secured at its lower extremity ; the sides are secured by 
hinges which allow them to be raised or lowered (Fig. 
249). A fracture-box of greater length is required for 
the treatment of fractures about the knee-joint. 

Bran, Sand, or Junk Bags. — These are constructed by 
taking a piece of unbleached muslin rive feet in length 
and fourteen and one-half inches in width, doubling it, 
and securing the free margins, except at the mouth, by 
stitches so as to form a bag : the bag is then inverted so 
that the edges of the seams are brought on the inner sur- 
face of the bag. The bag is next rilled with dry -and, 
bran. hair, or straw, and the mouth of the bag is closed 
by stitches or by beino; tied with a string. Bran bags 
with splints, or sand bags, are frequently employed in the 
treatment of fractures of the femur. 

Bandages. — The^e are made of muslin, and are used 
to retain splints in the treatment of fractures, and are 
also -ometimes applied directly to the injured part before 
the application of splints to control muscular spasm and 
limit the amount oi swelling ; when a bandage is so used, 
it is known as & primary roller. The use of the primary 
roller is sometimes of the greatest service in the dressing 




350 FRACTURES. 

of fractures, but its use iu inexperienced hands has so 
often been followed by unfortunate results in the early 
treatment of fractures, or in cases which are not under 
constant observation, that I think it a safe rule of prac- 
tice to discard entirely the use of the primary roller. 

Compresses. — These are made from a number of folds 
of lint, or of cotton or oakum, and are often employed to 
retain fragments in position or to 
Fig. 250. make localized pressure upon cer- 

tain points in the treatment of 
fractures. The compresses are 
held in position by strips of adhe- 
sive plaster, by a few turns of a 
roller-bandage, or by the splints. 
Rack for supporting bed- Compresses are sometimes em- 
WrySenSy^ 65 ~° f The P%ed to protect bony promi- 
nences of the skeleton from the 
pressure of the splints, but this purpose is often better 
effected by the use of small pieces of soap plaster spread 
on chamois skin fitted over the prominent points. 

Rack or Cradle. — This is made of wire or wooden 
hoops, and is often employed to support the weight of the 
bedclothes in the treatment of fractures of the lower ex- 
tremity (Fig. 250). 

Evaporating- Lotions in Fracture. — The employment 
of evaporating lotions such as lead-water and laudanum, 
or muriate of ammonium and laudanum, to the skin in the 
region of fractures is highly recommended by many sur- 
geons, especially in fractures involving or situated near 
joints. They are here employed to relieve pain, to limit 
inflammatory swelling, and to hasten absorption of the 
blood and serum at the seat of fracture. Many surgeons, 
on the other hand, think that their use causes irritation of 
the skin and delays the process of repair in the union of 
the fracture, and strongly condemn their employment. 
Personally, I have never seen bad results from their use, 
and have generally employed them in fractures near or 
involving the joints ; but I do not consider their employ- 
ment essentia], and when I use them I do so for only two 



SEPARATION OF THE EPIPHYSES. 351 

or three days. In cases of fractures accompanied with 
much pain and swelling, when the surgeon does not wish 
to use any of the lotions named, an ointment of ichthyol 1 
part, lanoline 3 parts, spread on lint and wrapped around 
the limb, will often prove a satisfactory dressing, or a 
layer of cotton may be -imply wrapped around the part 
before the application of the splints. 

Massage in the Treatment of Fracture. — Locas- 
Championniere advocates and practises immediate and 
contiuuous massage in the treatment of fractures, and 
holds that by its use pain is diminished, repair of the bone 
hastened by the profuse deposit of callus, and atrophy 
of muscles and stiffening of joints avoided. 

Massage is employed as soon as possible after the fract- 
ure has occurred, and consists in manipulations with the 
thumb, the fingers, or the whole hand. The limb is held 
by an assistant and extension is made, or it is placed upon 
a firm pillow or a sand cushion. The manipulations should 
be made in the direction of the muscular fibres and of 
the blood-current, and firm pressure should not be made 
directly over the seat of fracture. 

Massage should be practised for from fifteen to twenty 
minutes daily, and no retention apparatus should be ap- 
plied in the intervals unless there is marked tendency to 
displacement of the fragments, when some form of reten- 
tion apparatus or splint may be used. These manipula- 
tions should be continued for some weeks, until union is 
firm at the seat of fracture. Massage has also been com- 
bined with the ambulatory method of treatment of fract- 
ures of the lower extremity. This method of treating 
fractures by massage may be said to be still on trial, suffi- 
cient experience not yet having accumulated to prove that 
it possesses marked advantage over the generally adopted 
method of treatment by immobilization. 



SEPARATION OF THE EPIPHYSES. 

This lesion consists in a separation of the epiphysis of 
the bone from its diaphysis. The epiphyses are entirely 



352 FRACTURES. 

cartilaginous in infants, but ossification occurs later at 
various periods for different bones. The separation may 
occur at any time from birth up to the twenty-first year. 
The age at which traumatic separation of the epiphyses 
has been most observed is from the twelfth to the fifteenth 
year. Epiphyseal separations may be simple or compound. 

Simple Separations. — Traumatic separations of the epiph- 
yses may result from direct and indirect violence, from 
traction or torsion, and in rare cases from muscular action. 
The injury is always accompanied by stripping of the peri- 
osteum from the end of the shaft of the bone, but it gen- 
erally remains firmly attached to the epiphysis. Separation 
of the epiphyses in children results from the application 
of considerable force ; according to Poland, an injury 
which would be able to produce a dislocation in an adult 
will in a child usually result in a separation of an epiphy- 
sis. Separation of the epiphyses may result from disease, 
as in tuberculous and syphilitic ostitis and acute infective 
ostitis. Suppuration in the region of an epiphysis may 
result in its separation. 

Compound separations of the epiphyses are frequently 
met with, being most common at the lower epiphysis of 
the femur and the upper epiphysis of the humerus. 
These are grave injuries, from the fact that infection is 
apt to occur, resulting in suppurative osteomyelitis and 
necrosis, followed by arrest of growth of the limb and 
shortening. 

Symptoms. — These are mobility, deformity, crepitus, 
loss of function, pain, and swelling. Mobility, which 
exists at a point where it should not be observed, is a most 
important symptom, and is most marked if the separa- 
tion of the periosteum be extensive. Deformity is also 
more marked than in fractures, the smoothness of the 
separated surfaces permitting of displacement ; this varies 
with the amount of displacement of the diaphysis and the 
amount and mode of application of the force. Crepitus 
is soft and muffled ; loss of function is usually marked ; 
and pain and swelling at the seat of injury are soon fol- 
lowed bv extravasation of blood. 



SEPARATION OF THE EPIPHYSES. 353 

Diagnosis. — Separations without displacement are diffi- 
cult to diagnose, and are often considered as sprains of 
joints. In infants this lesion is difficult to recognize, and 
often escapes detection, but may be followed in a few 
weeks by swelling, suppuration, and symptoms of chronic 
osteomyelitis. 

Separation of the epiphyses is most apt to be confounded 
with fracture or dislocation ; the diagnosis is made from 
fracture by observing the line of separation, shape of the 
displaced epiphyseal fragment, the deformity (which is 
very characteristic in certain separations), and the soft 
character of the crepitus. From dislocation, the diagnosis 
is based upon the following signs : Dislocations are rare in 
infants and children. In separations of the epiphyses, if 
the displacement is reduced, it tends to recur upon re- 
moval of the force ; while in dislocation, if reduction is 
accomplished, it is not likely to recur when the force is 
removed. Rigidity is present in dislocation, while preter- 
natural mobility is marked in epiphyseal separation. In 
many joints the epiphysis will still be found to be con- 
nected with the joint and to retain its normal relations 
with the surrounding articular structures. In compound 
separations of the epiphyses the diagnosis may be made 
by observing that the displaced end of the bone is not 
covered by articular cartilage. 

Prognosis. — Union of the separated epiphyses occurs by 
the same process as that of a fracture. The amount of 
callus, which is formed largely by the periosteum uniting 
the fragments, varies with the completeness of their reduc- 
tion. Non-union has never been observed in this injury. 
Ankylosis of the neighboring joint may result in spite of 
the greatest care in the reduction of the deformity and in 
the treatment, yet permanent deformity may be present 
and interfere very little with the function of the limb. 
Arrest of growth of the limb after this injury in young 
subjects may be observed, but is not a necessary result, 
for the epiphyseal cartilage may perform its function as 
completely as before the injury, but is more apt to occur 
if the separation takes place between the epiphyses and 



354 FRACTURES. 

the epiphyseal cartilage, or the cartilage itself is severely 
injured. Arrest of growth is not marked in many cas s, 
for the reason that the injury occurs at a period when the 
growth of the skeleton is almost complete. 

Treatment. — This consists in redaction of the deform- 
ity, which in many cases i- difficult unless an anaesthetic 
be administered, and fixation of the parts after reduction 
by the use oi splints and bandages, the dressings employed 
being similar to those used in fracture at a corresponding 
portion of the bone. Muscular wasting should be pre- 
vented by the early employment of massage. Compound 
separations of the epiphyses are treated in the same 
manner as compound fractures, great care being taken to 
render the wound aseptic and to maintain it in this condi- 
tion. 

DRESSING OF SPECIAL FRACTURES. 

Fracture of the Nasal Bones. — Fractures of the nasal 
bones are often accompanied with fractures involving the 
septum, the nasal pr"<?ess of the maxillary bone, and the 
nasal spine of the frontal bone. 

Treatment. — This consists in replacing the fragments, if 
displacement exists, by manipulation with the ringers over 
the -eat of fracture and by pressure made from within the 
nostrils by a probe or a steel director. ^Yneu the displace- 
ment is once corrected, it is not apt to recur, and in the 
majority of cases no dressing is required. Before resort- 
ing to any manipulation within the uasal cavities the mu- 
cous membrane should be thoroughly cocainized to render 
the operation painless. When there is a return of the de- 
pression of the fragments or displacement of the septum 
after correcting the deformity by raising the depressed 
fragment, or bending the septum into place with a director, 
the parts may be held in position by packing the nasal 
cavity firmly with a strip of antiseptic gauze or by the use 
of Asch's tubes. 

In lateral displacements of the nasal bones from fract- 
ure, after reducing the displacement a small compress 



. 



FRACTURES OF MALAR BONE AND ZYGOMA. 355 

held over the fragment by strips of adhesive plaster will 
be the only dressing required. 

Mason transfixes the nose, after reduction of the frag- 
ments, with a stout needle, and steadies the pieces with a 
strip of plaster crossing the bridge of the nose and fast- 
ened to the ends of the needle. The needle is kept in 
position for eight or ten days (Fig. 251). 

Fig. 251. 




Mason's dressing for fracture of the nasal bones. 



Profuse hemorrhage sometimes occurs after fracture of 
the nasal bone-, and may require plugging of the nares to 
control it. Fractures of the nasal bones are usually quite 
firmly united in two weeks, and dressings may be dis- 
pensed with after this time. 

Fractures of the Malar Bone and Zygoma.— These 
fractures are usually the result of direct force ; the dis- 
placement is upward or backward, and when the zygo- 
matic arch is broken the fragments from pressure upon 
the masseter muscle or on the tendon of the temporal 



356 



FRACTURES. 



muscle may interfere with the movements of the lower 
jaw in mastication. This displacement is corrected by 
cutting down upon the fragment and elevating it or by 
passing a tenaculum into the fragment and raising it. 
Outward displacements may be corrected by pressure and 
the application of a compress. 

Treatment. — The dressing of these fractures after the 
correction of the deformity consists in the application of 
a compress of lint over the seat of fracture, held in posi- 
tion by strips of adhesive plaster or a bandage. There is 
little tendency to recurrence of the deformity after it has 
been corrected, and union at the seat of fracture is usually 
firm at the end of three weeks. 

Fractures of the Upper Jaw. — These fractures may 
involve the body, the nasal processes, or the alveolar proc- 
esses. 

Treatment. — The deformity should be corrected, and if 
any teeth have been displaced they should be replaced ; 
if there is comminution of the alveolus, the teeth in the 

Fig. 252. 




Dressing for fracture of the upper jaw. 



separate fragments may be fastened together by fine wire 
to fix the fragments and hold them in place ; the teeth 
of the lower jaw should be brought up in contact with 



FRACTURES OF THE LOWER JAW. 357 

those of the upper jaw, and the jaws should be secured 
together by the application of a Barton's or a Gibson's 
bandage (Fig. 252). Interdental splints, made of cork, 
with grooves to fit the teeth, or of gutta-percha, are also 
employed in the dressing of these fractures. The patient 
should not be allowed to move the jaw in mastication, and 
should be nourished by liquid and semisolid food, which 
may be taken without removing any teeth to give space 
for its introduction. The bandage should be removed 
every second or third day, and it should be reapplied in 
the same manner. Union is usually firm at the end of 
four or five weeks, and dressings may be dispensed with 
at this time. 

Fractures of the Lower Jaw. — The lower jaw may be 
broken at or near the symphysis, the most usual seat of 
fracture being near the mental foramen ; it is often broken 
at two places at once, and the fractures are in many cases 

Fig. 253. 




Dressing for fracture of The lower jaw. 



rendered compound by laceration of the mucous mem- 
brane, or the injury may consist in a separation of a por- 
tion of the alveolar process of the bone. 

Treatment. — The dressing of a fracture of the lower 



358 FRACTURES. 

jaw, after reducing the displacement and replacing any 
loosened or detached teeth, consists in applying a pad of 
lint under the chin and bringing the jaw up against the 
upper jaw, holding the compress in place, and securing the 
jaws firmly in contact by applying a Barton's (Fig. 253), 
modified Barton's, or Gibson's bandage. The bandage 
should be removed and reapplied at the end of the second 
or third day, and at like intervals during the course of 
treatment. The patient should be fed upon a liquid or 
semisolid diet, not being allowed to chew solid food until 
union at the seat of fracture has become firm. A very 
satisfactory temporary dressing for a fracture of the lower 
jaw consists in the application of a four-tailed sling. 

Some surgeons prefer to use an external splint moulded 
from pasteboard or gutta-percha fitted to the chin in the 
dressing of this fracture (Figs. 254 and 255), this being 

Fig. 254. Fig. 255. 




Shape of splint before being fitted to chin. Splint moulded to fit 

(Roberts.) chin. (Roberts.; 

padded with cotton and held in place by a Barton's or 
Gibson's bandage. Where there is much difficulty in 
keeping the fragments in position wiring together of the 
teeth may be employed, or the fragments may be perfor- 
ated with a drill and held in place by a strong silver wire 
suture ; interdental splints of metal or gutta-percha are 
also sometimes used for this purpose. During the course 
of treatment of fracture of the jaws the mouth often be- 
comes very offensive from fermentation of the saliva and 
discharges, and it is well to use frequently a mouth-wash 
of chlorate of potassium and tincture of myrrh, or boric 
acid solution. 



FRACTURES OF THE RIBS. 359 

The dressings : >r fracture of the lower jaw are applied 
for four or six weeks, the union usually being quite tirni 
at the end of this time. 

Fracture of the Hyoid Bone. — In fracture of the 
hyoid bone, if displacement exists, its reduction is facili- 
ss ure made with the finger in the pharynx. 

Treatment. — This consists in enforced quiet and the use 
>inm if cough is a prominent symptom, and the 
inflammatory symptoms may require the employment of 
active local treatment. A dressing may sometimes be em- 
ployed with advantage, consisting of a splint of pasteboard 
<:»r leather moulded to the anterior portion of the neck. 

Fractures of the Larynx or Trachea. — In fractures 
of the larynx or trachea where there is little displace- 
ment and dyspnoea is not marked, the parts should be 
supported by the applicati (presses : lint held 

in place by strip- of adhesive plaster. If. on the other 
hand, the respiration is embarrassed or there i- free expec- 
toration of blood, tracheotomy should be performed, and 
if the injury be seated in the larynx the displacement of 
the fragments may be overcome by manipulation with the 

2 r or a director through the tracheal wound, or the 
larynx may be packed with a strip of antiseptic gauze to 
control hemorrhage or hold the fragments in position, the 
patient in the meantime breathing through a tracheotomy- 
tube secured in the tracheal wound : the packing should 
be removed in a few days, the tracheotomy-tube being 
permanently removed as £ as the patient can breathe 

rtably through the larynx with the tracheal wound 
In fracture of the trachea the opening into the 
trachea should be below or at the seat of injury. 

Fractures of the Ribs.— Fractures of the ribs are 
more frequent than fracture- of any cither bones of the 
trunk ; the ribs most commonly broken are those from the 
fourth to the tenth : the most common seat of fracture is 
near the anter: sterior portion : the displacement is 

usually not marked, unless a number nf ribs be broken. 
being prevented by the intercostal muscles and aponeui - i 

Treatment. — The dressing; of fractures of the ribs is 



360 



FRACTURES. 



Fig. 256. 



best accomplished by enveloping the side of the chest on 
which the rib or ribs are broken with broad straps of 
adhesive or rubber plaster. The adhesive straps should 
be two and a half inches in width and sufficiently long to 
extend from the spine to the middle of the sternum. The 
straps are warmed, and the first strap is firmly applied at 
the base of the chest, extending from the spine to the 
mid-sternal line ; a number of ascending straps are applied 
in this Avay, each strap overlapping the preceding one by 
about one-third of its width until half the chest is covered 
in (Fig. 256). This dressing usually gives the patient 
much comfort, and the straps need 
not be renewed until they become 
slightly loosened, usually at the 
end of a week or ten days ; they 
should then be renewed in the 
same manner. The dressings are 
usually dispensed with at the end 
of three or four weeks, as repair 
of the fracture is generally well 
advanced at this time. 

A satisfactory temporary dress- 
ing consists in surrounding the 
chest by a broad binder of stout 
linen or muslin ; indeed, some sur- 
geons prefer to employ this dressing during the course of 
treatment, but, as a rule, I think it is not as good a dress- 
ing as the adhesive plaster dressing, as the former con- 
fines the movements of both sides of the chest. 

Fractures of the Costal Cartilages. — These fractures 
often take place at the junction of the cartilages with the 
ribs or in the body of the cartilages, and the union of the 
fracture usually takes place by the production of a mass 
of bone at the seat of fracture. 

Treatment. — It consists in the application of strips of 
adhesive plaster applied in the same manner as for fract- 
ure of the ribs, and the dressings should be retained for 
about the same time. 

Fractures of the Sternum. — Fractures of the sternum 




Adhesive plaster dressing 
for fracture of the ribs. 
(Hamilton.) 



FRACTURES OF THE PELVIS. 



361 




are rare injuries, but diastasis of the bones of the sternum 
is a more common accident. 

Treatment. — The treatment for both fracture and dias- 
tasis is the same, and consists in the application of a com- 
press over the seat of fracture held in place by a broad 
bandage, or, better, by strips of adhesive plaster (Fig. 
257), applied so as to cover and fix the anterior portion 
of the chest, covering the 
entire length of the ster- Fig. 257. 

num. This dressing should 
be retained for at least four 
weeks, being renewed if it 
becomes loose at the end 
of a week or ten days. 

Fractures of the Pelvis. 
— These fractures may in- 
volve the ilium, ischium, 
pubis, or sacrum. Vertical 
fractures, either single or 
double, and separations of 
the pelvic bones from their 
junctions may also occur, and are often serious injuries 
from implication of the pelvic viscera. 

Treatment. — The reduction of the displacement should 
be first accomplished as far as possible by external manip- 
ulation, together with internal manipulation by the fingers 
introduced into the rectum, or into the vagina in the 
female. The patient should be placed upon a firm bed 
on his back, with the knees slightly flexed over a pillow, 
and the parts should be kept at rest by surrounding the 
pelvis with broad straps of adhesive plaster or a stout 
muslin binder, or by a firmly applied padded pelvic belt. 
The hip-joints should be kept at rest by the application 
of pasteboard splints or by sand bags. The dressings 
should be retained for a period of at least six weeks. 

When these fractures are complicated by injury of the 
pelvic viscera various operative procedures may be re- 
quired, which will compel the surgeon to modify the 
method of dressing. 



Adhesive plaster dressing for fracture 
of the sternum. 



362 FRACTURES. 

Fractures of the Sacrum and Coccyx. — The dressing 

of fractures of the sacrum, after effecting reduction of the frag- 
ments as far as possible by pressure from within the rectum, 
consists in the application of broad adhesive straps around the 
pelvis, the patient at the same time being kept at rest in bed. 

When the coccyx is fractured, after reduction of the dis- 
placement, which may sometimes be accomplished by 
manipulation with the finger in the rectum, the patient 
should be confined to bed and the bowels kept at rest by 
the use of opium by suppository. The patient should 
remain in bed for two or three weeks. 

Fractures of the Vertebrae. — Fractures of the verte- 
brae are always most serious injuries, not only from the 
damage to the bones themselves, but also from that to the 
spinaf cord, membranes, and nerves, which often accom- 
panies them. These injuries are often associated with dislo- 
cations of the vertebrae, so that the term fracture-dislocation 
is used to describe them. In transporting or turning in bed 
a patient suffering from fracture of the vertebrae great care 
should be exercised, for rough or sudden motions may cause 
a displacement of the fragments which might, by injury of, 
or pressure upon, the spinal cord, rapidly prove fatal. 

Treatment. — If the deformity is marked, efforts should 
be made to reduce it by extension and counter-extension ; 
and the result may be successful, especially if the fracture 
be associated with a dislocation of the vertebrae. In some 
cases the use of permanent extension by means of weights 
attached to the legs, shoulders, and chest by adhesive 
plaster and bandages, has been successful in reducing the 
deformity. Laminectomy may be practised in certain cases. 

The patient should be placed upon his back upon a bed 
with a hair mattress, or better, if it can be obtained, a 
water-bed, which consists of a rubber mattress filled with 
water, which distributes the weight of the patient's body 
evenly over the surface. Whatever form of bed be used, 
the greatest care should be exercised to keep the patient 
absolutely clean, and the parts of the body or limbs which 
are exposed to pressure should be frequently bathed with 
alcohol or soap liniment ; and to distribute the pressure, 
small pads should be placed under the parts and changed 



FRACTURE OF THE SKULL. 363 

at intervals. These precautions are necessary to prevent, 
if possible, the formation of extensive bedsores, which are 
a frequent and troublesome complication of these injuries. 

The boivels should be carefully watched, and, if consti- 
pation is present, it should be relieved by the use of ene- 
mata ; and, as it is not desirable to lift the patient to slip 
a bed-pan under him, the discharges may be received in a 
flat tin plate pushed under the thighs and buttocks, or on 
pads of oakum or old muslin. 

The care of the bladder is also a matter of the greatest 
importance ; the retention which at first exists should be 
relieved by the use of a flexible catheter carefully steril- 
ized and introduced with great gentleness, and when incon- 
tinence supervenes a catheter which has been thoroughly 
sterilized should also be used at intervals ; the employ- 
ment of a soft instrument, if used with care, is not apt 
to produce injury to the urethra or bladder. 

The employment of a plaster-of-Paris jacket has been 
followed, in some cases, by good results, and it may be 
applied early in the case, or after the patient has been 
kept in the recumbent posture for some weeks ; by its 
use it is often possible to get the patient out of bed and 
allow him to sit in a chair. 

In fractures involving the cervical vertebrce, care should 
be exercised in lifting or moving the head ; it is often of 
advantage in these cases to apply short sand bags to the 
sides of the neck and head, to give additional fixation to 
the parts while the patient is in the recumbent posture, or, 
if he is allowed to get out of bed, to apply a moulded 
leather or pasteboard splint to the neck, shoulders, and 
back of the head, for the same purpose. 

The course of treatment in cases of fractures of the ver- 
tebrae, if the patient does not succumb to the injury in a 
few days or weeks, often extends oyer many months, and 
recovery is often more or less incomplete as regards the 
function of the parts below the seat of fracture. 

Fracture of the Skull. — Treatment. — This depends 
largely upon the nature of the injury — whether simple 
or compound — and the condition of the cranial contents. 



364 FRACTURES. 

In simple fractures unaccompanied with cerebral symp- 
toms no special dressing is required, but in compound 
fractures where loose fragments are present, these should 
be removed ; and if there is no depression of the frag- 
ments, and if no cerebral symptoms are present, the 
wound should be drained, carefully closed and dressed 
antiseptically, the dressings being held in place by a recur- 
rent bandage of the head. The patient should be put to 
bed, and the use of an ice-cap to the head is often of ser- 
vice. The diet should be restricted, while calomel and 
opium or bromide of potassium should be administered ; 
it is well to keep the patient for a few weeks in a quiet 
and darkened room. Where cerebral symptoms are pres- 
ent, either in simple or compound fractures, and trephin- 
ing is resorted to, the dressing of the wound is similar, 
and the same general treatment should be adopted. In 
all cases of fracture of the skull, whether subjected to 
operative treatment or not, it is well to keep the patient 
at rest in bed for three or four weeks, and he should be 
cautioned to avoid excesses afterward, and should not re- 
sume active work for some months. 

Fractures of the Clavicle. — Fractures of the clavicle 
may be complete or incomplete, and in the latter variety 
of injury the deformity is not usually very marked. The 
indications for treatment in complete fractures of the clav- 
icle are to relax the sterno-cleido-mastoid muscle, to pre- 
vent the weight of the arm on the injured side from 
dragging down the outer fragment of the clavicle, and, by 
fixing the scapula, to carry the attached external frag- 
ment outward and forward. A large variety of dressings 
have been devised and used to accomplish these objects. 

Dressing by Position. — The treatment of fractures of the 
clavicle by position is accomplished by placing the patient 
in bed on his back upon a firm mattress with a low pillow 
under his head, and the arm on the side of injury should 
be fastened to the side of the chest by a few circular turns 
of a bandage passing around the arm and chest ; the de- 
formity is usually very satisfactorily reduced upon the 
patient assuming this position, and after three weeks' rest 






FRACTURES OF THE CLAVICLE. 



365 



in this position the union is generally sufficiently firm to 
allow the patient to get out of bed and be about with the 
arm bound to the side or carried in a sling or with a Vel- 
peau bandage applied, without any recurrence of the 
deformity. 

Temporary Dressing. — A satisfactory temporary dressing 
for fractures of the clavicle consists in the application of 
a four-tailed bandage ; the bandage is made from a piece 
of muslin two yards in length and fourteen inches in 
width ; a hole is cut in its centre about four inches from 
its margin, to receive the point of the elbow ; the bandage 



Fig. 258. 



Fig. 259. 




Four-tailed bandage for fracture of Posterior figure-of-eight dressing for fract- 
the clavicle. (Stimson.) ure of the clavicle. (Hamilton.) 



is then split into four tails in the line of the hole and to 
within six inches of it ; the body of the bandage should 
be applied so that the point of the elbow rests in the hole, 
and a folded towel being placed in the axilla, the lower 
tails should be carried, one anteriorly, the other poste- 
riorly, diagonally across the chest and back, to the neck on 
the side opposite the seat of fracture, and secured ; the 
remaining tails are next carried around the lower part of 



366 



FRACTURES. 



the chest and secured so as to fix the arm to the side of 
the body (Fig. 258). 

In some cases the deformity is corrected by the applica- 
tion of a posterior figure-of-eight bandage, the forearm on 
the side of injury being carried in a sling (Fig. 259). 

Sayre's Dressing. — This consists of two strips of adhesive 
plaster three and a half inches wide and two yards in 
length. The first strip is looped around the arm just 
below the axillary margin, and is pinned or sewed with 



Fig. 260. 



Fig. 261. 





Sayre's dressing for fracture of the 
clavicle. First strip applied. 



Sayre's dressing for fracture of the 
clavicle. Second strip applied. 



the loop sufficiently open not to constrict the arm. The 
arm is then drawn downward and backward until the 
clavicular portion of the pectoralis major muscle is put 
sufficiently upon the stretch to overcome the action of the 
sterno-cleido-mastoid muscle, and in this way draws the 
sternal fragment of the clavicle down to its place. The 
strip of plaster is then carried completely around the body 



FRACTURES OF THE CLAVICLE. 367 

and pinned or stitched to itself on the back (Fig. 260). 
The second strip is next applied, commencing upon the 
front of the shoulder of the sound side ; thence it is carried 
over the top of the shoulder diagonally across the back, 
under the elbow, diagonally across the front of the chest 
to the point of starting, where it is secured by pinning or 
tewing. A slit is made in this strip to receive the point 
of the elbow. Before the elbow is secured by the plaster 
it should be pressed well forward and inward (Fig. 261). 

Fig. 262. 







Velpeau dressing tor fracture of the clavicle. 

Velpeau's Dressing. — This may also be used in the 
treatment of fractures of the clavicle (Fig. 262). A com- 
press may also be secured by the vertical turns of this 
bandage over the seat of fracture if needed. The appli- 
cation of the bandage is described on page 64. 



368 FRACTURES. 

In any form of dressing in which the arm is held 
against the side of the chest it is well to apply a folded 
towel or piece of lint between the arm and chest to pre- 
vent the skin surfaces from becoming excoriated. 

Fig. 263. 




Modified Velpeau dressing for fracture of the right clavicle. 

Modified Velpeau' s Dressing. — A modified form of Vel- 
peau's dressing for fracture of the clavicle is applied as 
follows : A soft towel or piece of lint is placed against 
the side of the body and over the front of the chest, and 
held in position by a strip of adhesive plaster; the arm 
is next placed in the Velpeau position, a good-sized pad 
of lint is next applied over the scapula, and this is held 
in place by a strip of adhesive plaster two and a half 
inches in width and one and a half yards in length ; this 
strip is continued downward and forward so as to pass 
over the point of the elbow, and is carried diagonally 
across the chest to the shoulder of the opposite side, and 
is secured, a slit being cut in it to receive the point of 
the elbow ; a compress of lint is next placed over the seat 
of fracture and held in place by a strip of adhesive plas- 
ter ; an additional strip of plaster is next carried from the 



FRACTURES OF THE CLAVICLE IN CHILDREN. 369 

spine around the arm and chest and secured on the oppo- 
site side of the chest; circular turns of a roller-bandage 
are then passed around the chest, including the arm from 
below upward until the arm is securely fixed to the body, 
and the dressing is finished by making one or two turns 
of the third roller of Desault (Fig. 263). Or the turns 
of the third roller of Desault may be applied first, and 
the dressing may be finished by circular turns of a roller 
passing around the arm and chest, extending from the 
elbow to the shoulder. 

The removal of dressings and their reapplication will 
depend upon the comfort of the patient and the manner 
in which they keep their position. As a rule, in fractures 
of the clavicle the dressings are removed at the end of 
the second or third day, the parts are inspected, and the 
skin is sponged with dilute alcohol ; the dressings are 
then reapplied, and if the patient is comfortable and the 
parts are in good position, the dressings are made at less 
frequent intervals until union is completed at the seat of 
fracture. 

Union in cases of fracture of the clavicle is generally 
quite firm at the end of four or five weeks, and at this 
time the dressings may be removed, and the patient 
should carry the arm of the affected side in a sling for 
several weeks, and should not undertake any work requir- 
ing forcible movements of the arm until eight or ten 
weeks have elapsed from the receipt of the injury. 

Fractures of the Clavicle in Children. — In the treat- 
ment of fractures of the clavicle in children the Velpeau 
or modified Velpeau dressing will be found to be the most 
satisfactory dressing to employ ; and as these patients are 
particularly apt to disarrange the dressings, it is well to 
render them additionally secure by applying a few broad 
strips of adhesive plaster over the turns of the roller-band- 
age, the strips following the turns of the bandage. 

The time required for union in fractures of the clavicle 
in children is somewhat shorter than in adults ; the dress- 
ings may be removed at the end of three weeks. 

Fractures of the Scapula. — Fractures of the scapula 

24 



370 FRACTURES. 

may involve the body, neck, acromion, or coracoid process 
of the bone. Fractures of this bone are rare, those of 
the acromion process being most common. 

Fracture of the Body of the Scapula. — Treatment. — If 
deformity is present, it is reduced by manipulation, and 
compresses of lint are placed above and below the seat 
of fracture and held in place by adhesive strips; the arm 
is next fixed to the side of the body by spiral turns of a 
roller-bandage passing around the arm and chest, and the 
forearm is supported in a sling. 

Fracture of the Neck, Acromion, or Coracoid Process of 
the Scapula. — Treatment. — The treatment of these fract- 
ures consists in placing a pad of lint or a folded towel 
in the axilla and binding the arm to the body by spiral 
turns of a roller-bandage passing around the arm and 
chest, and supporting the forearm in a sling. These fract- 
ures may also be dressed by first placing a pad of lint or 
a folded towel in the axilla and then securing the arm in 
the Velpeau position by the application of a Velpeau 
bandage (Fig. 262). In fractures of the acromion or 
coracoid processes the union is usually fibrous. In the 
treatment of fractures of the scapula the 
Fig. 264. dressing should be retained for about four 
weeks. 

Fractures of the Humerus. — Fractures 
of the humerus may involve the upper ex- 
tremity, the shaft,, or the lower extremity of 
the bone. 

Fractures of the Upper Extremity of the 
Humerus. — These include fractures of the 
head and anatomical neck of the bone, 
fractures through the tuberosities, fractures 
through the surgical neck of the humerus, 
and separation of the upper epiphysis of the 
humerus. 
Moulded splint for Treatment.— The most satisfactorv dress- 

shoulder and arm. . n /» , n ,i i i 

ing tor all tractures ot the humerus above 
the upper third of the bone is applied as follows : A 
primary roller should be evenly applied from the tips of 




FRACTURES OF THE HUMERUS. 371 

the fingers to the seat of the fracture, the arm being flexed 
at the elbow before the bandage is carried above this 
point, to prevent the dangerous constriction which might 
result if the bandage were applied with the arm in the 
straight position, and it were afterward flexed at the 
3lbow. A folded towel or a thin pad of lint should next 
be placed in the axilla and over the outer surface of the 
chest, to furnish a firm basis of support for the humerus, 
and also to prevent excoriation from the contact of the 
skin surfaces. A splint of pasteboard, felt, or leather 
(Fig. 264) is next moulded to the shoulder and arm ; 
this should be long enough to extend some distance below 

Fig. 265. 




Dressing for fracture of the upper extremity of the humerus. 

the seat of fracture and wide enough to cover in about 
one-half of the circumference of the arm, and is padded 
with cotton and fitted to the shoulder and arm. The splint 
and arm are next secured to the side of the body by spiral 
turns of a roller-bandage, including the arm and chest in 
its turns and applied from the elbow to the top of the 
shoulder. The forearm is carried in a narrow sling sus- 
pended from the neck (Fig. 265). This dressing should 



372 FRACTURES. 

be removed at the end of twenty-four or forty-eight hours, 
and after the parts have been inspected and sponged with 
alcohol the dressings should be reapplied in the same 
manner, and if the patient is comfortable they need not be 
disturbed again for three or four days, subsequent dress- 
ings beiug made at the same intervals. Union in fractures 
of the upper extremity of the humerus, except in those 
within the capsule, in which bony union is the exception, 
is usually quite firm at the end of five or six weeks, and 
the dressings can be dispensed with at this time. 

Separation of the Upper Epiphysis of the Humerus. — This 
accident is not uncommon in patients under twenty years 

Fig. 266. 




Separation of upper epiphysis of the humerus. 

of age, and may be confused with fracture of the neck of 
the humerus. There is usually a marked projection of the 
upper extremitv of the lower fragment in front of the 
shoulder (Fig. 266). 

Treatment. — This consists in reducing the displacement 
by manipulation, and the dressing is similar to that em- 



FRACTURES OF THE HUMERUS. 



373 



ployed in fracture of the neck of the humerus (Fig. 265). 
The functional result following this injury is usually very 
good. 

Fracture of the Shaft of the Humerus. — This fracture 
may occur at any point between the surgical neck and the 
condyles of the humerus ; the line of fracture is usually 
oblique. 

Treatment. — This consists in the application of a pri- 
mary roller from the tips of the fingers to the seat of fract- 
ure ; a short, well-padded, wooden splint extending from 
the axilla to a point a little above the internal condyle is 
next placed on the inner surface of the arm and against 



Fig. 267. 




the chest ; a moulded pasteboard or felt splint, fitted to 
the shoulder and outer side of the arm and extending a 
short distance below the seat of fracture, is padded with 
cotton and applied to the shoulder and arm. The splints 
are held in position by the turns of a bandage, and the 
arm is secured to the body by spiral turns of a roller-band- 
age carried around the chest and arm, and the forearm is 
carried in a sling suspended from the neck. The dressing 
is much the same as that for fracture of the upper part of 
the humerus, with the addition of the short internal splint. 
Fracture of the shaft of the humerus may also be dressed 
by first applying a primary roller and then placing the fore- 
arm and arm upon a well-padded internal angular splint 



374 FRACTURES. 

(Fig. 267). Care should be taken to see that the end of 
the splint extends only to the axilla and does not press 
upon the brachial vein. A pasteboard or felt moulded 
splint is next applied to the shoulder and outer side of the 
arm, and should be long enough to extend below the 
seat of fracture. The splints are held in position by turns 
of a roller-bandage beginning at the fingers and carried 
up to the shoulder, and finished with a few spica-of-the- 
shoulder turns (Fig. 268). If there is great overlapping 

Fig. 268. 




Dressing for fracture of the shaft of the humerus with internal angulai spliii' 
and external splint of binders' board. 

of the fragments producing marked shortening, the patient 
should be kept in bed and the elbow flexed, and weight or 
elastic extension made by adhesive strips applied to the 
arm, short coaptation splints also being applied. If the 
patient is treated as a walking case, the same result can be 
accomplished with a bag of shot or weight fastened to the 
arm so as to hang below the elbow. The arm is supported 
by a sling applied at the wrist, and sometimes for addi- 
tional security the arm is bound to the side of the body by 
spiral turns of a bandage carried around the arm and chest. 
The after-treatment of these fractures as regards the re- 
moval and renewal of the dressings is the same as in cases 



FRACTURES OF THE HUMERUS. 



375 



of fracture of the upper portion of the humerus ; the dress- 
ings should be retained for five or six weeks. 

Fractures of the Lower Extremity of the Humerus. — These 
include fractures at the base of the condyles, splitting frad- 



Fig. 269. 




Anterior angular splint. 



ures between the' condyles or those of the internal or exter- 
nal condyle,2iud epiphyseal separation of the lower epiphysis 
of the humerus. 

Treatment. — The displacement is reduced by extension 
and manipulation, and before applying any splint it is 



Fig. 270. 




Dressing for fracture of the lower extremity of the humerus with anterior 
angular splint. 

well in many cases to apply over the region of the fracture 
several layers of cotton-wadding. An anterior angular 
splint (Fig. 269) well padded with cotton or oakum is 



376 



FRACTURES. 



next applied and held in position by the turns of a roller- 
bandage applied from the fingers to the upper portion of 
the splint (Fig. 270). These fractures may also be dressed 
with a well-padded internal angular splint, this splint 
being substituted by an anterior angular splint at the end 
of ten days or two weeks. 

Some surgeons prefer to dress fractures of the condyles 
of the humerus with the arm in the extended position upon 
a straight anterior splint, or with short, narrow pasteboard 
splints applied around the joint, as favoring more accurate 

Fig. 271. 




Gunstock deformity after fracture of the condyle of the humerus. 



coaptation of the fragments, and diminishing the tendency 
to what is known as gunstock deformity and loss of the 
carrying angle (Figs. 271, 272). If this position is em- 
ployed, a straight wooden splint is applied to the anterior 
surface of the arm and forearm, or moulded splints of 
pasteboard may be used, and after the union is moderately 
firm, at the end of two weeks, the elbow should be flexed 
and kept in this position during the remaining time of the 
treatment. 



FRACTURES OF THE HUMERUS. 377 

Treatment by Acute Flexion (Jones's Method). — In tins 
dressing of fractures of the condyles of the humerus, the 
displacement of the fragments is corrected by manipula- 
tion and the forearm is placed in a position of acute flexion 
at the elbow, and the hand of the injured arm is brought 
up and is supported by a sling carried around the neck (Fig. 
273). The flexion of the forearm on the arm may also be 
rendered more secure by passing broad strips of adhesive 
plaster or a bandage around the arm and forearm. This 

Fig. 272. 




Showing loss of carrying angle after fracture of the condyle of the humerus. 

dressing is applied for three or four weeks, and then re- 
moved and the arm gradually extended. By this method 
of dressing the fragments are firmly held in position, better 
motion is obtained, and the tendency to gunstock deformity 
is diminished. The more extended use of this method of 
dressing fractures of the condyles of the humerus has 
shown that the practical results obtained are most satisfac- 
torv. 



378 



FRACTURES. 



When fractures of the lower extremity of the humerus 
involve the elbow-joint, a certain amount of impairment 



Fig. 273. 




Dressing for fracture of condyles of humerus in acute flexion. 

of joint-motion is apt to occur either from anchylosis or 
from displacement of the fragments, giving rise to gunstock 
deformity and loss of the carrying angle, which in many 
cases it is impossible to reduce completely, so that flexion 
and extension of the joint are restricted. Bearing these 
facts in mind, it is well to make passive motion in these 
cases as early as the second or third week. It is well to ex- 
plain to the patient or his friends that impairment of joint- 
motion may result in these fractures in spite of the great- 
est skill and care in the treatment. In a case of fracture 
in the region of the condyles of the humerus the dressings 
should be removed in twenty-four hours, and should be 
redressed in the same manner, and if the swelling does 
not increase and the dressing is comfortable to the patient 
it should afterward be dressed at less frequent intervals : 



FRACTURES OF THE OLECRANON. 



379 



the union is generally quite firm at the end of four weeks, 
and the splint may be removed at this time. Fractures 
of the condyles of the humerus are very common in 
children, and epiphyseal separations of the lower epiphysis 
of the humerus are also met with ; the dressing of these 
injuries in this class of patients is similar to that described 
for fractures of the condyles of the humerus. 

Fractures of the Olecranon Process of the Ulna. — 
Fracture of the olecranon may consist in simply a sepa- 
ration of the cortical layer of bone over the summit of 
the process to which the triceps is principally attached, or 
the line of fracture may pass through the sigmoid fossa. 

Treatment. — This fracture is dressed with the arm 
slightly flexed at the elbow, or with it completely 
extended ; the former position is possibly a little less irk- 
some to the patient. The separation of the fragment by 
the action of the triceps muscle is usually not very 
marked ; but, if the displacement is considerable, it may 
in a measure be overcome by the use of a compress above 
the fragment, over which figure-of-eight strips of adhesive 
plaster are fastened to draw it down into position (Fig. 
274). The ends of the strip are then attached to a well- 

Fig. 274. 




Adhesive straps applied in fracture of the olecranuii. 

padded straight splint which should be long enough to 
extend from the upper third of the arm to the ends of 
the fingers, and is secured in position by the turns of a 
roller carried from the fingers to the upper extremity of 
the splint, with figure-of-eight turns at the elbow to rein- 
force the action of the strips of plaster (Fig. 275). 



380 * FBACTUBE& 

This fracture may also be dressed by first applying a 
primary Toller to the elbow, and then placing over the 
arm a well-padded anterior obtuse-angled splint, or a 
straight splint with a good-sized pad of lint or oakum 
fastened at a point corresponding to the position of the 
flexure of the elbow. AY hen either of these splints is 
placed upon the arm a p >sition of moderate flexion is ob- 
tained. A compress of lint is next placed above the frag- 
ment, if there is a displacement, and one or two narrow 
strips of adhesive plaster are fastened over this and passed 
obliquely downward and attached to the splint on either 
side. The splint is then securely fastened to the arm by 
the turns of a roller-bandage applied from the fingers to 
the upper end of the splint. 

Fig. 275. 




Fracture of olecranon dressed in the extended position. 

The dressings should be removed at the end of twenty- 
four or thirty-six hours, or sooner if there is evidence of 
-welling of the tissues in the region of the fracture, and 
they should be reapplied in the same manner. If the 
dressing is comfortable to the patient, and there is no evi- 
dence of swelling, the subsequent dressings should be 
made at less frequent intervals ; the dressings are usually 
retained in this fracture for five or six weeks. Passive 
motion should not be made until this time, as flexion of 
the elbow tends to separate the fragments, unless union 
has taken place. The union of a fracture of the olecranon 
is in most cases fibrous, but in a few instances bony union 
has been observed. 



FRACTURES OF THE ULNA AND RADIUS. 381 

Fracture of the Coronoid Processof the Ulna. — Fract- 
ure of the coronoid process is an extremely rare injury. 

Treatment. — This is accomplished by placing the arm 
in a flexed position and applying a well-padded internal 
right-angled splint, or an anterior right-angled splint, and 
securing it to the arm by the turns of a roller-bandage. 
A moulded pasteboard or leather gutter may be substituted 
for the angular splint. The dressings should be changed 
at intervals, and after their removal, at the end of three 
or four weeks, passive motion should be practised. 

Fractures of the Head and Neck of the Radius. — 
These fractures are also quite rare. 

Treatment. — This consists in reducing the fragments by 
manipulation, by flexing the elbow and keeping it in this 
position, and by the application of a well-padded anterior 
right-angled splint, the splint being firmly secured in posi- 
tion by the turns of a roller-bandage applied from the tips 
of the fingers to the upper end of the splint (Fig. 27"). 
The splint should be changed at intervals, and should not 
be permanently removed for four weeks, at which time 
passive motion, consisting in flexion and extension at the 
elbow and pronation and supination of the forearm, should 
be made. 

An internal angular splint applied to the inner surface 
of the forearm and arm may also be used in the treatment 
of these fractures (Fig. 267). 

Fractures of the Ulna and Radius. — These fractures 
are often met with as the result of direct or indirect 
violence. 

Treatment. — After reducing the displacement, which is 
always marked when both bones are broken, by making 
extension from the hand and by manipulation, the forearm 
is placed in the supine position or in a position between 
pronation and supination. The supine position is, as a 
rule, to be preferred in any fracture of the radius, as the 
upper fragment is supinated by the action of the biceps 
and supinator brevis muscles, and, therefore, unless the 
lower fragment be placed in the supine position, union 
with rotary deformity will almost inevitably ensue. 



382 FRACTURES. 

Two straight wooden splints, well padded, a little wider 
than the forearm, are employed. The anterior splint 
should be long enough to extend from the elbow to the 
tips of the fingers, and the posterior splint should extend 

Fig. 276. 




Dressing for fracture of both bones of the forearm. 

from the elbow to the wrist. A primary roller should 
never be applied to the forearm in dressing these fractures, 
as its application diminishes the interosseous space, and its 
use has been followed by gangrene of the hand and fore- 
arm. In applying the anterior splint to the palmar sur- 
face of the forearm and hand, care should be taken that 
the upper end of the splint does not press upon the 
brachial artery and basilic vein at the elbow when the 
forearm is flexed ; the posterior splint is next applied from 
the elbow to the wrist, and the splints are held in position 
by the turns of a bandage carried from the fingers to the 
elbow (Fig. 276). 

In dressing this fracture a posterior splint equal in 
length to the anterior splint may be used in place of the 
short posterior splint extending from the elbow to the 
wrist. 

In fracture either of the shaft of the radius or of the 
ulna alone, the deformity is usually not so marked as 
when both bones are broken at the same time, the un- 
broken bone acting as a splint ; the dressing for these 
fractures is the same as for fracture of both bones of the 
forearm. 



FRACTURE OF LOWER END OF THE RADIUS. 383 

The dressing should be removed in twenty-four or 
thirty-six hours, and after inspecting the parts and spong- 
ing them with dilute alcohol, the splints should be replaced 
in the same manner and secured. The dressings should 
be renewed at intervals of two or three days for two weeks 
at least, and after this time the dressings should be made 
at less frequent intervals. The time required for union in 
these fractures is usually five or six weeks, and the splints 
should be retained for this time. 

Incomplete Fractures of the Ulna and Radius. — 
In children these fractures are very common. 

Treatment. — The deformity is reduced by bending the 
bones back into place, often converting the incomplete 
fracture into a complete one. After reduction of the de- 
formity, the treatment adopted is the same as that de- 
scribed above. In these patients there is a great tendency 
to displace the splints or rather to draw the forearm out 
of the splints, and to prevent this I often employ an anterior 
angular splint, in place of the straight anterior one, the 
upper portion of which, being fastened to the arm, prevents 
the child from dragging the arm out of the dressings. 



Fig. 2 




Fracture of the radius near its lower extremity, 

Fracture of the Lower End of the Radius. — The 

most common fracture of the radius is one situated from 
one-half of an inch to one and one-half inches above the 
lower articular surface of the bone (Colles's fracture), the 
line of fracture being more or less transverse, although it 
may in some cases be slightly oblique ; the characteristic 
deformity in this fracture is represented in Fig. 277. 
Numerous a*-ray studies of this fracture have shown that it 



384 



FRACTURES. 



is a much more complicated injury than was formerly sup- 
posed, being often comminuted or impacted and associated 
with a fracture of the styloid process of the ulna or of the 
scaphoid or semilunar bones. 

Treatment. — The most important point in the treatment 
of this fracture is to effect complete reduction of the frag- 
ments before the application of any splint ; this is done 
by making extension from the hand, and, at the same 
time, by over-extending and then flexing the wrist and 
by manipulation, the deformity can usually be completely 

Fig. 278. 




r 



■^J^^m 



M 



Position of compress in Colles's fracture. 

reduced. The arm should then be brought into the posi- 
tion of supination, and a firm compress of lint is next 
placed over the lower end of the upper fragment on the 
palmar surface of the forearm ; a second compress is then 

Fig. 279. 




Bond's splint. 



placed over the upper end of the lower fragment (Fig. 
278), and a well-padded Bond's splint (Fig. 279) is applied 



FRACTURE OF LOWER END OF THE RADIUS. 385 

to the palmar surface of the arm and held in place by the 
turns of a roller-bandage (Fig. 280). 

Many surgeons treat this fracture with the hand in a 
position between pronation and supination, the thumb 





Fig. 280. 




& m 


,•.--, 


SKI 


■l ^KvLl 







Dressing for fracture of the lower end of the radius. 

pointing upward. A substitute for Bond's splint may be 
prepared by fastening a roller-bandage obliquely upon a 

Fig. 281. 




ilrV'kmrV ..y^^d^a-^A, ■\;^mt 



Substitute for Bond's splint. 

straight wooden splint as suggested by Dr. Hays (Fig. 
281). 

Another method of treating Colles's fracture after the 
reduction of deformity consists in placing upon the dorsal 
surface of the forearm a padded straight splint, extending 
from the elbow to the tips of the fingers, and a short 
straight splint upon the palmar surface of the arm, ex- 

25 



386 FRACTURES. 

tending from the elbow to the wrist (Fig. 282). These 
splints are held in position by a bandage, and the forearm 
carried in a sling with the hand inclined to the ulnar side 

Fig. 282. 







Anterior and posterior splints applied. 

(Fig. 283). The hand should be bandaged to the posterior 
splint for about seven days and then set free. The pos- 
terior splint should be left long for another week ; at the 
end of this time it should be shortened so as to extend 
only to the wrist-joint, and the patient should be en- 
couraged to use the fingers and make motions of the 
wrist. At the end of three weeks both splints should be 
removed, and the patient should carry the forearm in a 
sling for a few weeks longer and be encouraged to use the 
hand. 

The most important point in the treatment of this fract- 
ure is the complete reduction of the deformity at the first 
dressing, and if this has been satisfactorily done almost 
any splint may be used with a good result, and, indeed, 
some surgeons use no splint, applying only a compress 
over the seat of fracture, held in place by a strip of 
plaster, the arm being carried in a sling. 

The after-treatment of these fractures consists in remov- 
ing the splint and compresses after twenty-four or thirty- 
six hours and in sponging the surface of the skin with 



REVERSED COLLETS FRACTURE. 387 

dilute alcohol, and the compresses and splints should then 
be reapplied in the same manner ; the fracture should be 
dressed every second or third day for the first two weeks, 
and after this time it should be dressed at less frequent 
intervals. Union is usually quite firm at the end of four 
weeks, and the splint should be dispensed with at this 
time. A certain amount of stiffness of the wrist and 

Fig. 283. 




Dressing for Colles's fracture with long posterior and short anterior splint 

fingers is apt to follow this fracture, which is usually soon 
overcome by passive motion and physiological use of the 
parts. 

Epiphyseal Separation. — In children separation of the 
lower epiphysis of the radius is often met with, and its 
treatment is similar to that described above ; a Bond splint 
with compresses or two straight splints with compresses 
being the most satisfactory dressing to employ in this in- 
jury, the dressings being retained for three weeks. 

Reversed Colles's Fracture. — This is a rare fracture 
of the lower end of the radius in which the lower frag- 
ment is displaced forward instead of backward, the de- 
formity being the reverse of that seen in Colles's fracture. 

Treatment. — This consists in the reduction of the de- 
formity, the manipulation being the reverse of that em- 
ployed in Colles's fracture, and the dressings are similar 
to those employed in the latter, with the exception that 
the position of the compresses is reversed. 



388 FBACTURES. 

Fractures of the Carpal Bones. — These fractures are 
usually compound or open fractures, and are so frequently 
associated with extensive laceration of the arm and hand 
that operative measures have to be resorted to ; but if such 
is not the case, they are dressed, when compound, with an 
antiseptic dressing, and the hand and forearm are sup- 
ported upon a well-padded palmar splint held in place by 
a roller-bandage ; more or less impairment in the motion 
of the wrist is apt to follow these fractures. The dress- 
ings should be retained for three or four weeks, and after 
their removal passive motion should be employed to over- 
come as far as possible the joint-stiffness resulting. 

Fractures of the Metacarpal Bones. — These fract- 
ures are often met with as the result of direct or indirect 
force applied to the metacarpal bones. 

Treatment. — This consists in first reducing the de- 
formity, which is usually an angular one, the projection 

Fig. 284. 




V 

Agnew's splint for fracture of the metacarpal bones. 

of the angle being toward the back of the hand ; this is 
reduced by pressure with the fingers, and the hand and 
forearm should then be placed upon a palmar splint (Fig. 
284) with a pad of oakum or cotton under the palm ; a 
compress of lint is next placed over the seat of fracture, 
and the hand and forearm are bound to the splint by the 
turns of a roller-bandage (Fig. 285). At the end of three 
weeks union at the seat of fracture is usually quite firm, 
and the splint should be dispensed with at this time. 

Fractures of the Phalanges.— These may result from 
direct or indirect violence, and often present marked 
deformity. 

Treatment. — This consists in reducing the displacement 
by extension and manipulation, and in placing the finger 



FRACTURES OF THE PHALANGES. 



389 



in a moulded gutta-percha or pasteboard splint (Fig. 286), 
and securing the splint in position by the turns of a roller- 
bandage. When the proximal phalanx is fractured, a nar- 
row padded wooden splint extending from the end of the 



Fig. 285. 




Dressing for fracture of the metacarpal bones. 

finger to the wrist should be applied upon the palmar sur- 
face of the finger and hand, and a short dorsal splint should 
also be used ; if there is a tendency to lateral displacement, 
short lateral splints should also be employed, and the 
splints should be held in place by strips of plaster or by 

Fig. 2S6. 



ffPf^ 




Gutta-percha splint for fracture of phalanx. (Hamilton.) 



a roller-bandage (Fig. 287). Splints made from a piece 
of wire may be fitted to the finger and secured in the 
same manner. 

Union in fractures of the phalanges is usually firm at 
the end of three weeks, and the splints can be dispensed 
with at that time. 



390 FRACTURES. 

Fig. 287. 




Dressing for fracture of phalanx with anterior and posterior splints. 

Fractures of the Femur. — These may involve the neck, 
great trochanter, and upper end of the shaft, the shaft, or 
the lower extremity of the bone. 

Fractures of the Upper Extremity of the Femur. — These 
may involve the head, neck, the great trochanter, and the 
upper portion of the shaft of the femur. 

Treatment. — The patient should be placed in bed upon 
a firm mattress, and an extension apparatus made from 
adhesive plaster should be applied to the leg, extending 
as far as the knee-joint. The extension apparatus is 
constructed by taking a piece of adhesive plaster two 
and a half inches in width and long enough to extend 
from the outer side of the knee or middle of the thigh 
to four inches below the sole of the foot, and from this 
point back to the inner side of the knee or middle of 
the thigh ; in the centre of this strip is placed a block 
of wood, two and a half inches wide and four inches in 
length, with a perforation in its centre ; the block and 
the inner surface of the strip on each side are next faced 
with a similar strip of adhesive plaster to a point about 
an inch above each malleolus ; a few straps are next 
wound around the wooden block to fix the previously 
applied straps ; the strip of plaster is next warmed and 
applied to the sides of the leg and held in position by 
three or four strips of adhesive plaster carried around the 
leg at intervals (Fig. 288), and the plaster is made addi- 
tionally secure by the application of a roller-bandage 



FRACTURES OF THE FEMUR. 



391 



applied to the foot and leg and carried up to the knee. 
Volkmann's sliding foot-piece may be employed to make 
the extension more effective (Fig. 289). 



Fig. 288. 




Adhesive plaster extension apparatus applied to limb. (Ashhurst.) 

Through the perforation in the block or stirrup is fast- 
ened a cord which passes over a pulley attached to the 
bed, and to this cord is attached the extending weight. 



Fig. 289. 




Volkmann's sliding foot-piece. 



The extension apparatus being applied, lateral support is 
given to the leg and thigh by sand bags applied on either 
side ; the outer sand bag should extend from the foot to 



392 FRACTURES. 

the axilla, and the inner one from the foot to the groin. 
A. weight of five or ten pounds is attached to the extend- 
ing cord, and the lower feet of the bed should be raised on 
blocks a few inches high, to prevent the patient from slip- 
ping down in bed ; a pad of oakum or cotton should also 
be placed under the tendo-Achillis, to relieve the heel from 
pressure. This dressing is kept in place for from four to 
six weeks, and if union has occurred the patient is kept 
in bed for a few weeks longer and is then allowed to be 
about, using crutches. In the majority of cases of fract- 
ure of the neck of the femur fibrous union only takes 
place, and after employing the dressing before described 

Fig. 290. 




Smith's anterior splint for fracture of the femur. 

for six weeks the patient is allowed to get up and go about 
on crutches. It often happens that the subjects in whom 
these fractures occur are old and feeble, and if it is found 
that restraint in bed with the dressings here described is 
not well borne, under such circumstances they should be 
discarded and the patient allowed to sit up in bed with 
the limb resting on a pillow, or to get into a chair, the 
treatment of the local condition having to be disregarded, 
attention being given to the patient's constitutional con- 
dition. 

In fractures of the neck of the femur and of the upper 



FRACTURES OF THE FEMUR. 



393 



part of the shaft of the bone the anterior wire splint of 
Professor N. P. Smith is sometimes used with advantage; 
the limb being swung from the splint, the patient is able 
to move in bed without causing him pain or disturbing 
the fragments (Fig. 290). In fractures in the upper por- 
tion of the femur where there is marked tilting forward 

Fig. 291. 




Dressing for fracture of the femur with extension upon an inclined plane. 
(Agnew.) 

of the upper fragment Professor Agnew employed exten- 
sion made from the thigh and placed the limb upon a 
double inclined plane, maintaining this position during the 
treatment of the case (Fig. 291). With the same object 

Fig. 292. 




Double inclined fracture-box. 



in view, in place of the double inclined plane a double 
inclined fracture-box may be employed (Fig. 292), exten- 
sion being made from the thigh by means of adhesive 



394 FRACTURES. 

plaster strips applied above the knee, to which a weight 
is attached. 

Fracture of the Shaft of the Femur. — This is a fre- 
quent fracture, and is usually accompanied by marked 
shortening and angular or rotatory displacement of the 
fragments. 

Treatment. — The patient should be placed upon a fract- 
ure-bed or an ordinary bed with a firm hair mattress; an 
extension apparatus of adhesive plaster is applied, and 
extension is made by a weight attached to this, as pre- 
viously described. Lateral support is given to the limb 
by the application of two wooden splints — the outer or 
long one extending from the axilla to the foot, the inner 
or short one extending from the groin to the foot. The 
splints at their upper extremity should be about six 
inches in width and at their lower extremity about three 
and a half inches. The splints are wrapped in a splint 
cloth, which extends from the foot to the groin, and after 
this has been placed under the limb the splints are fixed 
in their proper positions, the short one to the inner side, 
the long one to the outer side of the limb. Between the 
limb and the splints are interposed bran bags : the outer 
bag should be long enough to extend from the axilla to 
the foot, the inner one from the groin to the foot. The 
splints and bran bags are held in place by five or six 
strips of bandage passing under the limb and body and 
around the splints and bran bags at intervals. The heel 
is saved from pressure by placing a wad of oakum or 
cotton under the tendo-Achillis, and after the splints have 
been brought into place the strips of bandage are firmly 
tied to secure them, and a weight of ten or twelve pounds 
is attached to the extending cord. The foot of the bed is 
raised, to prevent the patient from slipping downward and 
to allow the weight of the body to act as a counter- 
extending force. After the application of the dressings 
the thigh should be slightly abducted. During the after- 
treatment of these fractures the surgeon should see that 
the splints and bran bags are kept firmly in place, and that 
the foot does not roll outward ; this is accomplished by 



FRACTURES OF THE FEMUR. 



395 



untying the strips and readjusting the bags, and then 
bringing up the splints and securing them in position by 
fastening the strips (Fig. 293). The extension apparatus 
usually does not require renewal during the course of 
treatment. The extension apparatus and splints are kept 
in place for four or six weeks, and at this time union at 
the seat of fracture is usually quite firm, so that they may 
be removed, and the fracture is then supported by moulded 
pasteboard splints or by the application of a plaster-of- 
Paris splint for several weeks longer, and at the end of 
eight to ten w T eeks it is safe to allow the patient to be up 
and around on crutches. 

Fig. 293. 




Dressing for fracture of the shaft of the femur with lateral splints and 
bran bags. (Ashhxrst.) 

Many surgeons, in fracture of the shaft of the femur, 
prefer to use a long external sand bag, and a shorter 
internal one in place of the corresponding long and short 
splints and bran bags ; if care is observed that the sand 
bags are kept accurately in contact with the limb and 
body, excellent results may be obtained by this form 
of dressing. After considerable experience with both 
methods of furnishing lateral support in the dressing of 
fractures of the shaft of the femur, I am well satisfied 
that angular deformity is less likely to result where the 
splints and bran bags are employed. 

The plaster-of-Paris dressing, including the foot, leg, 



396 FRACTURES. 

thigh, and pelvis, is employed by some surgeons in the 
early treatment of fracture of the shaft of the femur, the 
limb being kept well extended until the plaster has thor- 
oughly set. In applying this dressing, the patient should 
be placed upon the pelvic supporter (see page 101). 

Fracture of the Lower End of the Femur. — The 
fractures met with in this portion of the femur are supra- 
condyloid fractures, those in which one condyle is sepa- 
rated from the other, or comminuted fractures, in which 
both condyles are separated ; epiphyseal disjunctions of 
the lower end of the femur, met with in young subjects, 
may also be classed with fractures at this portion of the 
bone. 

Treatment. — If there is shortening, the dressing should 
be similar to that employed in fractures of the shaft of 
the femur, consisting in the application of an extension 
apparatus and bran bags and splints or sand bags to give 
lateral support ; if, however, there is no marked shorten- 
ing, the dressing employed should be the same as that 
applied in fractures involving one or both condyles or 
epiphyseal separation. 

The dressing employed in fracture of one or both con- 
dyles or in epiphyseal disjunction of the lower end of 
the femur consists in placing the limb in a fracture-box 
extending from the foot to the upper third of the thigh, 
the box being well padded with a soft pillow, or a well- 
padded posterior splint, or a moulded pasteboard or felt 
gutter may be employed ; if either of these dressings is 
employed, the splint or gutter should be sufficiently long 
to extend from the lower part of the leg to the upper part 
of the thigh. 

At the end of two weeks it is well to place the limb 
in a plaster-of-Paris dressing extending from the foot 
to the upper part of the thigh. This dressing should 
be retained for six weeks ; at the end of this time the 
dressing should be removed, and if union is sufficiently 
firm to allow the patient to go about on crutches, a fresh 
plaster-of-Paris splint should be applied extending from 
the middle of the leg to the middle of the thigh, or lateral 



FRACTURES OF THE FEMUR. 397 

splints of pasteboard may be substituted for the plaster 
dressing. 

A certain amount of permanent impairment of the 
joint-motion is apt to follow fractures involving one con- 
dyle or both condyles of the femur. 
* Fracture of the Shaft of the Femur in Children. — 
Treatment. — In infants the treatment by extension by a 
weight and pulley and lateral splints is often unsatisfac- 
tory on account of the difficulty in keeping the patient 
quiet upon his back, and from the soiling of the dressings 
by the feces and the urine. In children two years of age 
and over I have never found much trouble in employing 
extension and lateral support by splints and bran-bags or 
sand-bags, and in these cases I make additional fixation 
at the seat of fracture, and guard against displacement 
of the fragments by the child sitting up in bed when not 
watched, by carefully moulding external and internal 
pasteboard or felt splints to the thigh, and holding them 
in place by the turns of a bandage. I have employed 
this form of dressing even in children under two years 
of age with the most satisfactory results. 

In cases of fracture of the femur in children from a few 
months to a year or eighteen months of age, in whom it 
is difficult to obtain quietude, or who have to be moved to 
give them nourishment if theyare taking the breast, the 
dressing which I have found most satisfactory consists in 
first applying a roller-bandage from the foot to the groin, 
and then moulding to the outer half of the foot, leg, 
thigh, and also to half of the pelvis, a pasteboard or felt 
splint which is well padded with cotton, and held in posi- 
tion by the turns of a bandage carried from the foot to the 
pelvis and finished with circular turns about the pelvis. 
The splint should be so moulded as to include a little 
more than one-half of the circumference of the thigh and 
leg. If this splint becomes soiled, it is easily replaced by 
a fresh one, and its removal and renewal are much easier 
than the plaster-of-Paris splint which is recommended by 
some surgeons in these cases. 

In young children fractures of the femur are often in- 



398 



FRACTURES. 



complete or greenstick fractures ; and even when complete, 
the shortening is usually not marked, as the line of fract- 
ure is apt to be transverse, the periosteum often not being 
completely ruptured, which tends to hold the fragments 
in position. 

In green-stick fractures the deformity should be reduced 
by manipulation, even if it is necessary to convert the 
incomplete fracture into a complete one to accomplish 
this object. 

Mr. Bryant recommends that fractures of the femur in 
young children be treated in the vertical position ; the 
injured limb, together with the sound 
one, is flexed at a right angle to the 
pelvis and fixed with a light splint, 
and attached to a cradle or bar above 
the bed (Fig. 294). 

If the plaster-of- Paris dressing is 
used, the limb should first be envel- 
oped from the foot to the pelvis with 
a flannel bandage, and extension 
should be made while the plaster-of- 
Paris bandage is being applied, and 
should be kept up until the bandage 
has become fixed. The plaster band- 
age should extend from the toes to 
the pelvis, and it is well to fix the 
hip-joint by carrying several turns 
of the bandage about the pelvis. To 
prevent the splint from absorbing 
the discharges and becoming offen- 
sive, the upper portion of it may be coated with shellac. 
The time required for union in fractures of the femur 
in children is about four weeks, and the dressings may be 
removed at this time ; but the child should not be allowed 
to use the limb for several weeks after this period. 

Ambulatory Treatment of Fractures of the Femur. — In 
this method of treatment in fractures of the femur the 
injured limb is strongly extended, and a flannel roller is 
applied to the leg, thigh, and pelvis. A plaster-of- Paris 




Fracture of the femur 
treated by vertical exten- 
sion. (Bryant.) 



FRACTURES OF THE PATELLA. 



399 



bandage is then applied from the toes to the pelvis, and 
is made to include the pelvis by spiea and circular turns. 
It should be well padded in the perineum, and the inner 
portion of the bandage should lit well in the region of the 
tuberosity of the ischium. The plaster dressing should be 
so applied that upon the patient standing upon the limb 
the weight is supported by the plaster cast resting upon the 
tuberosity of the ischium and the expanded portion of the 
ilium. A Taylor hip-splint, reinforced by plaster bandages 
and the use of crutches, with a high shoe on the sound 
foot, may be used in the ambulatory treatment of fractures 
of the femur. 

Fractures of the Patella. — These fractures result from 
direct violence and muscular action. 

Treatment. — This consists, first, in the application of a 
roller-bandage from the toes to the upper part of the leg ; 



Fig. 295. 




Agnew's splint for fracture of the patella. 

a well-padded posterior wooden splint long enough to 
extend from the middle of the leg to the middle of the 
thigh, or an Agnew splint, which is provided with peo-s 
for the attachment of strips of adhesive plaster (Fig. 295), 
is next placed under the limb. A small compress of 
lint is next placed above the upper fragment, and a 
similar compress i- placed below the lower fragment : a 
strip of adhesive plaster one and a half inches in width 
and twenty-four inches in length has its middle portion 
applied over the compress, and its ends are then brought 
obliquely downward and fastened to the splint, or to the 
pegs if Agnew's splint be used ; this may be reinforced 



400 



FRACTURES. 



by a second or third strip. The object of these strips 
is to bring the upper fragment down in contact with the 
lower fragment. A strip of plaster with the ends passing 
in the opposite direction is next placed over the lower 
compress, and the ends are fastened to the splint or pegs ; 
this strip serves only to steady the lower fragment, as it 
cannot be drawn upward to meet the upper fragment by 
reason of the inextensibility of its ligamentous attachment 
(Fig. 296). If the Agnew splint is employed, the strips 
of plaster may be tightened by turning the pegs to which 
they are fastened without removing the splint. 

Fig. 296. 




Agnew's splint applied. 

The splint is next firmly fixed in contact with the limb 
by the turns of a roller-bandage extending from the lower 
to the upper end of the splint. The limb should next be 
placed upon an inclined plane or in a long fracture-box, 
with its foot elevated to relax the quadriceps femoris 
muscle. This dressing should be removed and reapplied 
in a few days, as the dressings become loose as the swell- 
ing about the seat of injury subsides, and after this disap- 
pears the dressings require renewal at less frequent inter- 
vals ; and usually at the end of three weeks the splint may 
be removed and a plaster-of- Paris bandage may be applied, 
extending from the middle of the leg to the middle of the 
thigh. At the end of six weeks the patient may be allowed 
to walk upon the limb, the knee-joint being fixed with a 
plaster-of-Paris or pasteboard splint. 



FRACTURES OF THE PATELLA. 401 

It is well, after removal of the splints, for the patients 
to wear for some months a laced muslin knee-supporter, 
which gives some support to the knee-joint. 

A great variety of splints have been devised and used 
in the treatment of fractures of the patella, the main object 
of which is to fix the knee-joint and bring the fragments 
as nearly as possible in apposition. 

The union in fractures of the patella is usually fibrous, 
although in rare cases bony union has occurred. 

In cases of rupture of the fibrous union after fracture 
of the patella, which is not an uncommon accident, the 
treatment of the case should be the same as that for 
a recent fracture of the patella. 

Operative Treatment. — This method, which consists in ex- 
posing the fragments by an incision and drilling and suturing 
them with catgut or silver-wire sutures, or in approximating 
the fragments by suturing the fibrous tissues with catgut, is 
the most satisfactory procedure and the one most employed 
at the present time, the strictest antiseptic precautions being 
taken to prevent infection of the wound. After the external 
wound has been closed without drainage, the limb is put up in a 
plaster-of- Paris dressing extending from the foot to the groin. 

Fractures of the Bones of the Leg. — In fractures 
of both bones of the leg the displacement is usually very 
marked. When only one bone is broken, the sound bone, 
acting as a splint, prevents much deformity, except in cases 
of fracture at the lower end of the fibula, when the foot 
inclines to the injured side. 

Treatment. — The dressing of fractures of both bones of 
the leg, or of fracture of the tibia or the fibula alone, 
except in cases where the lower portion of the fibula is the 
seat of injury, is best accomplished by the use of a fracture- 
box. The displacement being overcome as far as possible 
by extension and manipulation, the leg is placed in a 
fracture-box, which is prepared for the reception of the 
limb by having the sides let down and having a soft pillow 
laid in it ; the foot is next secured to the footboard by a 
loop of bandage passed around the foot, the ends being 
tied after passing through the slots in the footboard ; a pad 
of oakum or cotton is placed under the tendo-Achillis, to 

26 



402 



FRACTURES. 



relieve the heel from pressure, and a similar pad is placed 
between the sole of the foot and the footboard (Fig. 297). 
The sides of the box are then brought up and secured by 

Fig. 297. 




Application of the fracture-box. 



two or three strips of bandage tied around the box. In 
using a fracture-box in the treatment of fractures of the 
bones of the leg the surgeon should see that the foot is 



Fig. 298. 



r-" 



"■•/ 



Plaster bandage applied to fracture of the leg. 

kept well down to the footboard and is at a right angle 
with the leg, that there is no eversion of the knee, and that 
the pillow is full enough to make equable pressure upon 
the leg when the sides of the box are secured, and that 



FRACTURES OF THE BONES OF THE LEG. 403 



the heel is not subjected to undue pressure, the use of a 
pad of oakum or cotton under the tendo- A chillis being 
employed to prevent this complication. Where there is a 
tendency to tilting upward of the lower end of the upper 
fragment, the lower fragment can be brought in line with 

Fig. 299. 




Fracture-box suspended. (Aqnew.) 

this by raising the foot by a mass of oakum or cotton 
placed under the tendo-Achillis and heel, and so over- 
coming the deformity. In some cases division of the 
tendo-Achillis may be required before this deformity can 
be corrected. 

The subsequent dressings of the case are conducted 



404 



FRACTURES. 



by letting down the sides of the box and correcting any 
displacement, if present, by adjusting the limb and pads 
in their proper position, and again bringing up the sides 
of the box and securing them. At the end of two weeks 
the fracture-box may be removed and a plaster-of- Paris 
dressing applied to the limb, which will allow the patient 
more freedom of movement in bed, or permit of his sit- 
ting up without disturbing the fragments (Fig. 298). 

Fig. 300. 




Moulded binders' board splints for fracture of the leg. 

Union in fracture of the bones of the leg is usually 
quite firm in six weeks, but for at least eight weeks the 
patient should not be allowed to put his weight upon the 
limb in walking. 

If the patient is restless, and finds his position with the 
fracture-box resting upon the bed irksome, the fracture- 



FRACTURES OF THE BOXES OF THE LEG. 405 

box mav be swung from a frame fastened over the bed 
(Fig. 299). ' 

The application of a plaster-of-Paris dressing as a 
primary dressing — the ordinary plaster-of-Paris bandage 
or the Bavarian dressing being applied — in fractures of 
the bones of the leg is adopted by some surgeons, and, if 
employed, the case should be under constant observation 
for a few days, so that the dressing can be removed if a 
dangerous amount of swelling takes place. Moulded 
splints of felt or pasteboard are also sometimes applied in 
the treatment of these cases (Fig. 300). 

This fracture may also be treated with Volkmann's 
splint (Fig. 301), for one or two weeks, until the swell- 
ing has subsided, and then by a plaster-of-Paris dressing. 

Fig. 301. 




Volkmann's splint. 

In patients suffering with delirium tremens, or in mani- 
acal patients, the use of a fracture-box in the treatment 
of fractures of the bones of the leg is often not satisfac- 
tory, on account of the difficulty in restraining the move- 
ments of the patient and the consequent displacement of 
the fragments. In such cases it is well to applv a few 
strips of binders' board, well padded with cotton, to the 
limb, extending above and below the seat of the fracture, 



406 FRACTURES. 

holding them in place by a few turns of a roller, and then 
to wrap the limb and foot in a soft pillow, and hold this 
in place by the turns of a roller-bandage applied with 
moderate firmness. This dressing allows the patient to 
move the limb without serious disturbance of the frag- 
ments, and, after the patient recovers from his attack, the 
leg may be placed in the fracture-box or in a plaster-of- 
Paris dressing. 

In fractures of the bones of the leg in young children 
the same difficulty is often experienced in keeping them 
quiet, and for this reason a fracture-box cannot be used 
with satisfaction. In dressing these cases, two lateral 
splints of pasteboard, moulded to the foot and leg and 
well padded with cotton, may often be employed with the 
best results. The splints should not be wide enough to 
meet on the anterior or posterior surface of the leg or 
foot. The splints, after being carefully adjusted, are held 
in place by the turns of a roller-bandage ; and after these 
splints have been applied for two weeks, and all swelling 
has subsided at the seat of fracture, a plaster-of-Paris 
bandage may be substituted for them, which should be 
worn for three weeks; at the expiration of this time 
union is usually sufficiently firm to dispense with all dress- 
ings. 

Ambulatory Treatment of Fractures of the Bones of 
the Leg. — The application of a dressing for the ambu- 
latory treatment of fractures of the bones of the leg is as 
follows : The fracture should be reduced and the skin of 
the leg washed with soap and water ; a flannel bandage 
is applied from the toes to a point just above the knee. 
This bandage holds to the sole of the foot a number of 
layers of cotton-wadding, which, when moderately com- 
pressed, makes a pad three-quarters of an inch in thick- 
ness. A plaster-of-Paris bandage is applied to the foot 
and leg, and extends above the knee, and care should 
be taken to apply additional turns about the sole of the 
foot and ankle, to give it greater strength at these points. 
The turns of the bandage should also be firmly applied 
about the expanded head of the tibia. 



FRACTURES OF THE FIBULA. 407 

In the ambulatory method of treatment, the patient, as 
soon as the bandage has become firm, is allowed to walk 
about, first with crutches or a cane, and fiually bearing 
his weight upon the injured limb. 

Fractures of the Fibula. — In fractures of the fibula, 
with the exception of that fracture occurring at the lower 
end of the bone, the deformity is not marked, and they 
are usually dressed with a fracture-box applied as in the 
dressing of fractures of both bones of the leg. and at the 
end of two weeks a pla^-ter-of-Paris dressing should be 
applied, and the patient allowed to get out of bed and 
move about on crutches. The union in a fracture of the 
fibula is usually quite firm at the end of five weeks, at 
which time all dressings may be dispensed with. 

Fracture of the Lower End of the Fibula (Pott's Fract- 
ure). — This fracture usually occurs in the lower fifth of 
the bone, and is often associated with laceration of the 
internal lateral ligament of the ankle-joint or a sprain- 
fracture of the internal malleolus, and is usually accom- 
panied by marked eversion of the foot. 

Treatment. — After reducing the displacement by exten- 
sion and manipulation, the limb should be placed in a 
fracture-box provided with a soft pillow, the foot should 
be secured to the footboard, and a pad of oakum or cotton 
should be placed under the tendo-Achillis : before bring- 
ing up the sides of the box and securing them, two firm 
compresses of lint or oakum should be placed in contact 
with the leg and foot, one just above the inner malleolus, 
the other just below the outer malleolus. The sides of 
the box are next brought up and secured, and by the 
pressure of these compresses the foot is brought into an 
inverted position and the deformity is corrected. 

The after-dressing of this fracture consists in letting 
down the sides of the box, and in inspecting the parts to 
see that the foot is kept in the proper position, and care 
should be taken that undue pressure is not made upon the 
skin by the compresses, which might result in ulceration ; 
this may be avoided by sponging the skin with alcohol 
and changing the positions of the compresses slightly at 



408 



FRACTURES. 



each dressing. At the expiration of ten days the fract- 
ure-box and compresses may be removed and the limb 
put up in a plaster-of- Paris dressing, including the foot 
and leg, up to the knee. The patient may then be allowed 
to go about on crutches, and at the end of five weeks all 
dressings may be dispensed with. 

This fracture may also be treated by the forcible cor- 
rection of the deformity under ether and the immediate 
application of a plaster-of-Paris dressing. 

Dupui/trens splint, which consists of a straight wooden 
splint long enough to extend from the condyles of the 
femur to the end of the toes, may also be employed ; 
this splint is provided with padding, the thickest part of 
which, several inches in thickness, should rest upon the 
skin just above the inner malleolus when the splint is 

Fig. 302. 




Dupuytren's splint applied. 



applied to the inner side of the leg. The splint is secured 
in position by the turns of a roller applied over the foot 
and at the upper part of the leg (Fig. 302). After using 
this dressing for a few clays, if the displacement is satis- 
factorily corrected, the splint may be removed and the leg 
placed in a fracture-box or in a plaster-of-Paris dressing;. 

Fractures of the Tarsal Bones. — The ealeaneum and 
astragalus are the tarsal bones most frequently fractured. 

Treatment. — The dressing of fractures of the ealea- 
neum, after reducing the displacement, which is not 
usually marked unless the posterior portion of the bone 
is involved, by manipulation, consists in placing the 
leg and foot in a fracture-box, care being taken that 
the foot is kept at a right angle to the leg. When 



FRACTURES OF THE PHALANGES OF THE TOES. 409 

the fracture involves the posterior portion of the bone, 
and there is displacement by the action of the muscles 
inserted into the fragment, the leg should be flexed upon 
the thigh and the foot extended ; this position may be 
maintained by applying a well-padded curved splint to the 
anterior portion of the leg and foot and securing it in 
position by a bandage. 

Fractures of the astragalus, after reducing any defor- 
mity which is present by extension and manipulation, are 
dressed by placing the foot and leg in a fracture-box, care 
being taken that the foot is kept at a right angle to the 
leg. This precaution is important, as anchylosis not in- 
frequently occurs after this fracture, and if the foot is in 
the proper position it is much more useful to the patient. 

As soon as the swelling, which is usually very marked 
after fracture of the calcaneum or astragalus, subsides, the 
foot and leg should be put up in a plaster-of-Paris band- 
age. The amount of tension and the inability to reduce 
the displacement in cases of fracture of the astragalus may 
be indications for excision of the fractured bone. The 
time required for union in fractures of the tarsal bones is 
from five to six weeks. 

Fractures of the Metatarsal Bones. — These fractures 
are dressed by placing the foot upon a well-padded plantar 
splint, and using compresses to hold the fragments in place 
if there is much displacement, the splint and compresses 
being held in position by a bandage ; or they may be 
treated by placing the foot and leg in a fracture-box, the 
footboard of the box acting as a plantar splint ; the plaster- 
of-Paris dressing may also be used in these cases. The 
time required for union in fracture of the metatarsal bones 
is from three to four weeks. 

Fractures of the Phalanges of the Toes. — These fract- 
ures are often compound and attended with so much 
laceration of the soft parts that immediate amputation is 
required ; when, however, the fractures are simple, or in 
compound fractures where amputation is not required, the 
dressing consists in applying a plantar splint of wood or 
binders' board, extending beyond the toes and securing it 



410 FRACTURES. 

in position by the turn- of a roller-bandage. When a 
single toe only is broken, a moulded splint of gutta-percha 
or binders' board may be applied, and a portion of the 
splint should extend some distance upon the s<:»le of the 

foot, to fix the proximal joint, and also to give the toe a 
firm point of Fixation : the moulded splint should be held 
in position by a narrow roller-bandage or by strips of ad- 
hesive plaster. The time required for union in fractures 
of the phalanges of the toes is about three weeks. 



COMPOUND OR OPEN FRACTURES. 

In the dressing of compound or open fractures the same 
dressings and splints which are generally used in the treat- 
ment oi simple or closed fractures may be employed: the 
wound in the 90ft parts requires a special dressing, and this 
should be so arranged as to secure free drainage and pro- 
mote its prompt healing. In some cases of compound 
fracture the treatment 01 the injuries of the soft parts 
demands attention first, and in such cases the injury to the 
bones is for a time disregarded, care being taken that 
the fragments are kept quiet, so as to prevent further 
damage to the soft parts until the wound is in such a 
condition that the proper manipulation to reduce the dis- 
placement and fix the fragments by splints and suitable 
dressings may be undertaken without interfering with the 
repair of the wound. 

Treatment. — In the dressing of compound or open 
fractures the skin surrounding the wound should first be 
carefully cleansed, and the wound next be thoroughly irri- 
gated with a 1 : 2000 bichloride solution, and any foreign 
bodies or loose fragments of bone removed: if there is 
hemorrhage, it should be controlled by securing the bleed- 
ing vessels with ligatures. The reduction of the dis- 
placement should next be accomplished by making ex- 
tension and by manipulation : if the fragments project 
from the wound, before this can be satisfactorily accom- 
plished it may be necessary to enlarge the wound and 



COMPOUND OB OPEN FRACTURES. 411 

to resect one or both ends of the fractured bones, and 
in some cases it may be necessary to drill the ends of 
the fragments and introduce a strong wire or catgut 
suture, or a metallic nail, screw, or plate, to hold them in 
their proper positions. After reduction of the displace- 
ment the wound should again be thoroughly irrigated with 
an antiseptic or normal salt solution, and after making 
provision for drainage by the introduction of a drainage- 
tube or tubes, counter-openings being made to secure free 
drainage if necessary, sterilized or antiseptic gauze dress- 
ings should be applied. 

The wound, if a small one, need not be closed witli 
sutures ; but if extensive, a few catgut, silk, or silkworm- 
gut sutures may be applied to bring the edges of the wound 
into apposition, care being taken to avoid making undue 
tension ; if the soft parts have been much lacerated or 
contused, it is better to introduce no sutures. If the 
limb is much swollen and the wound is a small one, free 
division of the deep fascia to relieve tension and secure 
drainage is often followed by good results. A final irri- 
gation of the wound through the drainage-tube is next 
made, and the wound is covered by a bichloride gauze 
dressing and a number of layers of bichloride cotton, the 
whole dressing being held in position by a gauze bandage 
applied with moderate firmness. 

The reduction of the fragments and the dressing of 
the wound having been accomplished as described, the 
splints appropriate for a similar fracture, if it were a 
simple or closed one, are next applied. If the surgeon 
has been able to render the wound aseptic, and has applied 
an antiseptic dressing, the compound fracture is often 
soon converted into a simple one by the prompt healing 
of the wound, and the patient may exhibit no more 
constitutional disturbance than he would have with a 
similar simple or closed fracture. The redressing of a 
compound fracture dressed in this way need not be made 
for a week or ten days, unless there is a rise in the 
patient's temperature or the dressings become soaked with 
discharges from the wound, or they become uncomfortable 



412 



FRACTURES. 



to the patient by reason of swelling of the soft parts in 
the region of the wound. When redressing of the fract- 
ure becomes necessary the dressings are removed, and the 
drainage-tubes may also be removed if no longer needed ; 
the wound being redressed with an antiseptic or aseptic 
dressing, the splints are reapplied, and, after the wound is 
healed, the subsequent dressing of the fracture should be 
the same as that of a simple fracture. The time required 
for union in a compound fracture is usually much longer 
than in a corresponding simple fracture. 

Plaster-of-Paris Dressing. — This may be used as a primary 
dressing in compound fractures; the displacement being 



Fig. 303. 




Fenestrated plaster dressing for compound fracture of the leg. 



reduced and the wound dressed with an antiseptic gauze 
dressing, a plaster-of- Paris bandage is applied to the parts 
so as firmly to fix the fragments ; the joints on either side 
of the fracture should be fixed by the bandage, and the 
parts should be held in position until the plaster has set 
firmly. After the plaster has become firm a fenestrum 



COMPOUND OR OPEN FRACTURES. 413 

should be made over the position of the wound, so that it 
may be inspected or dressed through this when necessary 
(Fig. 303j. The ends of a piece of stout wire, bent into 
a semicircle, may be incorporated in the turns of the plas- 
ter bandage above and below the position of the fenestrum, 
to give it additional strength after the removal of a portion 
of the bandage to make the fenestrum. 

If the plaster-of- Paris dressing is applied as a primary 
dressing in compound fractures, the case should be carefully 
watched for a few days, and if much swelling occurs at the 
seat of fracture its removal and renewal are indicated ; 
profuse discharge of serum may also soak the dressings 
and bandage, so that its renewal is necessitated. Some 
surgeons, therefore, prefer to defer the application of the 
plaster-of-Paris dressing in compound fractures for a few 
weeks until the swelling has diminished and the wound is 
nearly or quite healed ; the wound being covered with an 
antiseptic dressing, the plaster bandage is applied, and a fe- 
nestrum is made over the position of the wound if required. 

Binders' Board or Felt Splints. — These may also be em- 
ployed in the dressing of compound fractures, being 
moulded to the parts after an antiseptic dressing lias been 
applied to the wound, and held in position by the turns 
of a roller-bandage. 

The principal advantage in the use of these splints is 
the ease with which they can be removed and reapplied if 
frequent dressings of the fracture are necessary for any 
reason. They may be used during the entire course of 
treatment ; or, after a few weeks, when the swelling has 
diminished at the seat of fracture and the wound is well 
advanced toward repair, they may be discarded and a 
plaster-of-Paris dressing substituted. In compound fract- 
ures of the bones of the leg, after reducing the displace- 
ment and applying an antiseptic dressing to the wound, I 
usually apply moulded binders' board splints to either side of 
the leg, including the foot, and place the leg in a fracture-box 
for additional security. In a week or ten days I discard the 
binders' board splints and apply a plaster-of-Paris dressing. 

A method of dressing compound fractures which has 



414 



FRACTURES. 



been introduced by Mr. Treves consists in rendering the 
skin in the region of the wound aseptic and removing any 
foreign bodies from the wound, then rendering it as far 
as possible aseptic ; powdered iodoform is then dusted 
thickly over the wound at intervals, and, mixing with the 
blood and serum from the wound, is allowed to dry, form- 
ing an antiseptic scab, the wound being exposed to the air, 
and the fragments are retained in position by splints or by 
a fracture-box. 

UNUNITED FRACTURE. 

This condition usually arises from local causes, such 
as imperfect coaptation of the fragments, the interpo- 
sition of muscular tissue, fascia, a tendon, or nerve, or 



Fig. 304. 



Fig. 305. 





Fragments in ununited fracture 
secured by silver wire. 



Fragments in ununited fracture 
secured by silver splint. 



a portion of devitalized bone between the fragments. The 
.ends of the bones may be rounded, or may be united by 



UNUNITED FRACTURES. 415 

fibrous tissue, or there may be an attempt at the forma- 
tion of a false joint, the end of one fragment being rounded 
off and the other cupped to receive it. 

Treatment. — This consists in exposing the ends of the 
bones by incision, with full antiseptic precautions, and 
removing the ends of the bones to secure a healthy sur- 
face, and then fixing the bones securely together by drill- 
ing them and introducing one or more heavy silver-wire 
sutures (Fig. 304). In some cases the shape of the 
fragments is such that they can be sawed so as to form a 
mortise, and the bones can then be fixed by the intro- 
duction of one or more steel or silver screws. Another 
method of fixation is by a steel or silver splint secured to 
the fragments by iron or silver screws (Fig. 305). After 
the fixation of the bones has been accomplished, the wound 
should be closed and an antiseptic dressing applied ; ad- 
ditional fixation is furnished by the application of a 
plaster-of-Paris dressing. 



PAET V. 
DISLOCATIONS 



Dislocation. — This consists in displacement of the ar- 
ticular surfaces of the bones which enter into the forma- 
tion of a joint. Dislocations may be complete, 'partial, 
simple, compound, and complicated, and they are ' also 
known as habitual, recent, and old dislocations. 

Complete Dislocation. — This is a dislocation in which 
no portions of the articular surfaces of the bones remain 
in contact with each other. 

Partial Dislocation. — This is a dislocation in which por- 
tions of the articular surfaces of the bones still remain in 
contact with each other. 

Simple Dislocation. — This is a dislocation in which 
there exists displacement in the relation of the articular 
surfaces of the bones with little injury to the soft parts 
adjacent to the joint, and the displaced ends of the bones 
do not communicate with the air by a wound in the soft 
parts. 

Compound Dislocation. — This is a dislocation in which 
there exists displacement of the articular surfaces of the 
bones which communicate with the air through a wound 
in the soft parts. 

Complicated Dislocation. — This is a dislocation in which, 
in addition to the displacement of the articular surfaces 
of the bones, there exists a fracture, or a laceration of 
important bloodvessels, nerves, or muscles in connection 
with the dislocation. 

27 417 



418 DISLOCATIONS. 

Habitual Dislocation. — This consists in a dislocation 
which constantly recurs upon slight provocation, and is 
usually due to a relaxed condition of the ligaments of 
the joint. 

Recent Dislocation. — This is a dislocation in which the 
displacement of the articulating surfaces of the bones has 
existed for such a period that time has not been afforded 
for inflammatory changes to take place in the articular 
surfaces of the bones or in the adjacent tissues which 
would seriously interfere with their reduction. 

Old Dislocation. — This is a dislocation in which the 
displacement of the articulating surfaces of the bones has 
existed for some time ; in this variety of dislocation the 
displaced bones often form firm adhesions to the surround- 
ing tissues, and the articulating surfaces often undergo 
changes. 

Treatment of Dislocations. — The first indication in 
the treatment of dislocations is to return the displaced 
articular surfaces of the bones to their normal position, 
and to retain them in this position by the use of suitable 
dressings. The return of the articular surfaces of the 
bones to their normal position, or the reduction of the dis- 
location, is accomplished by manipulation, extension, and 
counter-extension. The reduction of dislocations should 
be attempted as soon as possible after they have occurred. 

The principal obstacles to the reduction of dislocations 
are muscular resistance and the anatomical peculiarities 
of the joints. The former is best overcome by the use 
of an ancesthetic given to the point where complete mus- 
cular relaxation is produced. The resistance offered by 
the changed relations of the articular surfaces and the 
ligaments is to be overcome by the surgeon making such 
manipulations, founded upon his knowledge of the anat- 
omy of the parts, as will make the ligaments, muscles, and 
bones assist in the reduction of the dislocation. 

In recent dislocations, by the use of extension and 
manipulation, especially if an anaesthetic be employed, 
the reduction is usually accomplished without the use of 
much force; but in old dislocations, where absolute mus- 



SPECIAL DISLOCATIONS. 419 

cular shortening lias taken place, the use of extending 
bands is often required, and in securing these bands to the 
limb the clove-hitch knot is useful (Fig. 306). 

The treatment of dislocations after reduction consists 
in placing the joint at complete rest by the application of 
suitable splints and bandages, and in treating any inflam- 
matory complications, if they arise, by the application of 

Fig. 306. 




Clove-hitch knot applied. (ERICHSEN.) 



evaporating lotions, and in a week or two, after the injured 
ligaments have been repaired, passive motion should be 
resorted to for restoring the function of the joint. 



SPECIAL DISLOCATIONS. 

Dislocations of the Vertebrae. — Dislocations of the 
lumbar and dorsal vertebrce, as simple dislocations, are ex- 
tremely rare accidents ; they are occasionally met with, but 
are more often associated with fractures of the vertebra? in 
these regions. Uncomplicated dislocations of the cervical 
vertebra? are more common. The treatment of dislocations 
of the vertebra?, whether complicated with fracture or not, 
consists in attempting reduction by making extension and 
counter-extension with manipulation, and by this means, 
in many cases, the luxations may be reduced. If, however, 
the efforts at reduction are unsuccessful, permanent exten- 
sion should be applied by means of a weight extension 



420 



DISLOCATIONS. 



apparatus from both legs and from the shoulders and 
head. The after-treatment consists in keeping the patient 
at rest upon his back in bed upon a firm mattress, and if 
the cervical vertebrae have been involved, the head and 
neck should be supported by short sand bags ; and in case 
of the vertebra? below this point, the application of a 
plaster-of-Paris jacket may be used to give support and 
fixation to the part. The general management of the 
case as regards complications is similar to that in cases of 
fracture of the vertebrae. 

Dislocations of the Coccyx. — These are reduced by 
manipulations with the finger in the rectum and external 
manipulation at the same time. The only after-treatment 
required is rest in bed for a few days and the administra- 
tion of opium to keep the bowels quiet. 

Fig. 307. 




Bilateral dislocation of the lower jaw. (Ashhurst.) 

Dislocations of the Lower Jaw. — These dislocations 
may consist in the displacement of one or both condyles 



DISLOCATIONS OF RIBS AND COSTAL CARTILAGES. 421 

of the lower jaw from the glenoid fossse, constituting the 
unilateral or bilateral dislocation of the jaw ; the latter is 
the more common form of dislocation of the jaw met with, 
and the deformity resulting is shown in Fig. 307. 

The redaction of a dislocation of the lower jaw is accom- 
plished as follows : The surgeon placing his thumbs, well 
protected by strips of bandage or a towel, on the molar 
teeth or behind them, presses the angles of the jaw down- 
ward while he elevates the chin with his fingers, and by 
this manipulation the condyles of the jaw usually slip back 
into place with a snap (Fig. 308). After reduction of the 

Fig. 308. 




Method of reducing dislocation of the lower jaw. (Hamilton.) 

dislocation the jaw should be fixed for a week or ten days 
by the application of a Barton's bandage or a four-tailed 
sling. 

Dislocation of the Hyoid Bone. — A few cases of dis- 
location of the hyoid bone have been recorded ; the treat- 
ment consists in throwing back the head as far as possible, 
to place the muscles of the neck upon the stretch, depress- 
ing the lower jaw, and pressing the luxated bone into 
position. 

Dislocations of the Ribs and Costal Cartilages. — 
The ribs may be dislocated at their vertebral articulations 
or at the junction with the costal cartilages, or the carti- 
lages may be separated from the sternum. These injuries 
result from the application of great force, and are often 



422 DISLOCATIONS. 

fatal from associated injuries of the thoracic viscera. 
The treatment of these dislocations consists in reducing 
the displacement by manipulation and pressure, and then 
in fixing the chest to secure immobility of the ribs by 
strapping the affected side with strips of adhesive plaster, 
the same dressing being applied as in cases of fracture 
of the ribs, the dressing being retained for three or four 
weeks. 

Dislocations of the Sternum. — Dislocation or diastasis 
of the sternum may occur at the junction of the manu- 
brium and the gladiolus or at the junction of the ensiform 
cartilage and the gladiolus. The reduction is effected by 
extension of the chest by bending the dorsal spine over a 
firm cushion placed under the back and by pressure upon 
the projecting bone ; when the displaced bone has been 
reduced, a compress should be placed over the seat of in- 
jury, and held in place by broad strips of adhesive plaster, 
or by a bandage to keep the parts at rest. The dressing 
should be retained for three or four weeks. 

In the few examples of dislocation of the ensiform 
cartilage which have been reported, the displacement of 
the cartilage has in some cases given rise to persistent 
vomiting, which was relieved by reduction of the displace- 
ment ; it is, however, almost impossible to keep the bone 
in place after reduction. 

Dislocations of the Pelvis. — Dislocation or diastasis 
of the bones of the pelvis may occur at the pubic or 
sacro-iliac symphyses. They are generally serious in- 
juries, as they are apt to be complicated by lesions of the 
pelvic viscera. 

The reduction of these dislocations is effected by press- 
ure and manipulation, and after reduction the parts should 
be supported by a compress held in place by a stout binder 
or by broad strips of adhesive plaster, the patient being 
kept quiet in bed and the pelvis being supported by means 
of sand bags. The dressings should be retained for from 
four to six weeks. 

Dislocations of the Clavicle. — Dislocations of the clav- 
icle may occur either at the sternal or acromial end ; the 



DISLOCATIONS OF THE CLAVICLE. 423 

latter injury some writers describe as a dislocation of the 
scapula, following the general rule that the distal bone is 
the one dislocated. 

Dislocations of the Sternal End of the Clavicle. — These 
ma) 7 occur in a forward, backward, or upward direction, 
and the displacement is generally well marked (Fig. 309). 
The induction of this dislocation is effected by placing the 
knee against the spine, and drawing the shoulders outward 
and backward and pressing the displaced end of the clav- 
icle into place. The reduction is generally easy, but it is 
often difficult to keep the end of the bone in its proper 
position. To accomplish this, a compress should be placed 
over the end of the bone, and this should be secured in 
place by broad strips of adhesive plaster ; the shoulders 
should be brought well backward and secured by a pos- 
terior figure-of-eight bandage of the chest, and the arm 
of the injured side should be fastened to the side of the 
chest by spiral turns of a bandage. In some cases, in 
addition to the compress over the end of the bone, secur- 
ing the arm of the injured side in the Velpeau position 
will be found all that is necessary to retain the bone in 
position. 

Dislocation of the Acromial End of the Clavicle. — This 
may be upward, downward, or backward (Fig. 310). 
The reduction is effected by manipulation of the arm and 
scapula and by pressure over the displaced end of the 
clavicle. The displacement is usually reduced without 
much trouble, but it is often a matter of difficulty to keep 
the end of the bone in its proper place. The dressing 
consists in placing a compress over the acromial end of 
the clavicle and holding it in place by broad strips of 
adhesive plaster ; the arm should at the same time be 
fixed in the Velpeau position. 

Stimson's dressing consists in applying a long strip of 
adhesive plaster three inches wide, the centre being placed 
over the flexed elbow and its ends carried up in front of 
and behind the arm, crossing over the end of the clavicle 
and being secured on the front and back of the chest, 
respectively, while the bone is held in place by pressure 



424 



DISLOCATIONS. 



upon the clavicle and the elbow. For additional security, 
the forearm may be supported in a sling and the arm 
bound to the side of the chest. 

The dressings after reduction of dislocations of the 
clavicle should be kept in place for at least three weeks. 
Although in many cases a certain amount of deformity 
persists, the disability resulting from the injury is not 
often marked. 



Fig. 309. 



Fig. 310. 





Dislocation of sternal end of clavicle 
forward. (Bryant.) 



Dislocation of clavicle at acromial 
end. (Bryant.) 



Dislocations of the Scapula.— Dislocation of the acro- 
mion process of the scapula from the outer end of the 
clavicle, which has been described under dislocations of 
the acromial end of the clavicle, is classed by some writers 
as a scapular dislocation. 

Dislocation of the Inferior Angle of the Scapula. — The 
displacement of the inferior angle of the scapula from 
under the latissimus dorsi muscle is due to relaxation 
of this muscle and of the serratus magnus, and is some- 
times described as a dislocation of the inferior angle of 
the scapula. The reduction of this deformity consists in 
the employment of manipulation and pressure to over- 
come the displacement, and the use of a compress held 
in place by broad strips of adhesive plaster to secure the 
bone in its proper position. 



DISLOCATIONS OF THE SHOULDER. 425 

Dislocations of the Shoulder. — The head of the 
humerus may be dislocated downward, forward, or back- 
ward. 

Subglenoid Dislocation of the Head of the Humerus. — In 
this variety of dislocation the head of the bone rests in 
the axilla (Fig. 311). 

Fig. 311. 




Subglenoid dislocation of the head of the humerus. (Stimson.) 

Subcoracoid Dislocation of the Head of the Humerus.-^- 
Tn this variety of dislocation the head of the humerus 
rests beneath the coracoid process of the scapula (Fig. 
312). 

Subclavicular Dislocation of the Head of the Humerus. — 
This may be considered an aggravated form of the latter 
variety of dislocation ; the head of the humerus in this 
dislocation rests beneath the clavicle. 



426 



DISLOCATIONS. 



Subspinous Dislocation of the Head of the Humerus. — In 
this variety of dislocation the head of the humerus rests 
beneath the spine of the scapula (Fig. 313). 

Reduction of dislocations of the humerus is effected by 
manipulation, by extension and counter-extension, and by 
a combination of these methods. 

Manipulation in the reduction of subglenoid dislocation 
of the humerus is practised with the patient in the recum- 
bent posture by first flexing the forearm upon the arm to 



Fig. 312. 




Subcoracoid dislocation of the head of the humerus. (Stimson.) 

relax the long head of the biceps muscle ; the elbow is 
next seized and abducted so as to bring it to. the side of 
the patient's head, thus relaxing the deltoid and supra- 
spinatus muscles ; the surgeon or an assistant next places 
his hand upon the head of the humerus in the axilla, and, 
as the arm is drawn outward to a right angle with the 



DISLOCATIONS OF THE SHOULDER, 
Fig. 313. 



427 




Subspinous dislocation of the head of the humerus. (Erichsen.) 
Fig. 314. 




m 

Reduction of dislocation of the humerus by heel in the axilla. (Erichsen. 



428 



DISLOCATIONS. 



body by the other hand, he pushes the head of the bone 
into the glenoid cavity. 

In the reduction of subcoracoid and subclavicular dislo- 
cations the manipulations are the same, except that the arm 
is to be rotated outward before being carried downward. 

In the reduction of subspinous dislocations, after the arm 
has been abducted, it should be rotated inward and direct 
pressure made upon the head of the bone as the arm is 
abducted. 

Fig. 315. 




Kocher's method of reduction : first position. (Brewer.) 

Reduction may also be effected by extension and counter- 
extension, as in Cooper's method, where extension is made 
from the arm downward and counter-extension is made by 
the heel in the axilla (Fig. 314). This method is not to 
be recommended, on account of the damage which may 
occur to the axillary nerves and vessels. 



DISLOCATIONS OF THE SHOULDER. 



429 



Kocher's Method. — Place the patient in the sitting posture 
and flex the elbow to a right angle, at the same time pres- 
sing the arm against the chest ; the flexed forearm is 
then turned as far as possible from the trunk by rotating 
the humerus outward until it occupies a position parallel 
with the transverse plane of the body (Fig. 3 1 5). W bile the 
external rotation is being maintained the elbow is slowly 
carried upward along the anterior border of the chest 

Fig. 316. 




Kocher's method : second position. (Brewer.) 



until it reaches a point opposite the ensiform cartilage 
(Fig. 316) ; the forearm is then quickly rotated inward 
until the hand touches the opposite shoulder and the 
elbow is lowered (Fig. 317). 

3£othe's Method. — Reduction by this method may also 
be accomplished by extension made upward, the scapula 



430 



DISLOCATIONS. 
Fig. 317. 




Kocher's method : third position. (Brewer.) 
Fig. 318. 




Reduction of dislocation of the humerus by extension upward. 



DISLOCATIONS OF THE ELBOW. 431 

being fixed by the foot or hand placed over the acromion 
process (Fig. 318). 

After reduction of dislocations of the head of the 
humerus the arm should be bound to the side of the bodv 
by the turns of a spiral bandage of the chest, or should 
be held against the side by the application of a Velpeau's 
bandage ; this dressing should be removed at intervals of 
a few days, and after ten days or two weeks all dressings 
should be dispensed with, passive motion should be em- 
ployed, and the patient allowed to move the arm. 

Dislocations of the Elbow. — Dislocations of the bones 
of the forearm at the elbow may be either backward, for- 
ward, or lateral. The backward dislocation is the most 
common form (Fig. 319). 

Fig. 319. 




Dislocation of both bones of the forearm backward. iLiSToy.) 

The reduction of backward dislocations is effected by 
making traction upon the forearm and at the same time 
making pressure upon the lower end of the humerus as 
the forearm is flexed upon the arm. 

Or the reduction may be accomplished by bending the 
arm slowly and forcibly over the knee placed upon the 
inner surface of the elbow, so as to press upon the radius 
and ulna, separating them from the humerus and freeing 
the coronoid process from its abnormal position (Fig. 320). 

Lateral dislocations of the bones of the forearm at the 
elbow are reduced by making extension from the forearm, 
and at the same time making direct pressure on the dis- 



432 



DISLOCATIOSS. 



placed bones and counter-pressure on the lower end of the 
humerus. 

Forward dislocations of the bones of the forearm at the 
elbow are reduced by making forced flexion at the elbow, 
together with extension and counter-extension, or by mak- 
ing forced extension of the forearm at the elbow, pressing 
the humerus backward, and suddenly flexing the forearm. 

Fig. 320. 




Reduction with the knee in the bend of the elbow. (Hamilton.) 

The dressing, after the reduction of dislocations at the 
elbow, consists in the application of a well-padded ante- 
rior right-angled or slightly obtuse-angled splint, to keep 
the forearm in a flexed position — the dressing being prac- 
tically the same as that for fractures of the ToAver end of 
the humerus, with an anterior angular splint (Fig. 321). 
This dressing should be retained for two or three weeks, 
being removed at intervals of several days ; after the re- 



DISLOCATIONS OF THE HEAD OF THE RADIUS. 433 

inoval of the splint passive motion should be practised, to 
prevent stiffness of the elbow-joint. 





Fig. 321. 






^^^v. 


/ 






4 1 



Dressing after reduction of dislocation of the elbow. 

Dislocations of the Head of the Radius. — The head* 
of the radius may be displaced forward, outward, or back- 
ward, the forward dislocation being the most frequent. 
The reduction of these dislocations is effected by making 
extension from the forearm and counter-extension from the 
lower end of the humerus, and at the same time the head 
of the bone is pressed into its proper position. The 
dressing after reduction of the displacement consists 
in the application of a compress over the head of the 
bone, and the arm and forearm should be placed upon a 
well-padded anterior angular splint, which is secured by 
a roller bandage. The dressing is similar to that em- 
ployed after reduction of dislocations of the bones of the 
forearm at the elbow. Difficulty is sometimes experienced 
in keeping the head of the bone in position after reduction, 
so that the use of a compress in addition to the use of the 
splint is often required. The arm should be kept upon 
the splint for three weeks, being redressed at intervals. 

Dislocation of the Upper End of the Ulna. — The 
upper end of the ulna may be displaced backward, the 
olecranon projecting beyond the condyles of the humerus, 

28 



434 



DISLOCATIONS. 



while the head of the radius occupies its normal posi- 
tion. 

The reduction of this displacement is effected in the same 
manner as that of both bones of the forearm backward, 
and the dressing after reduction is similar to that employed 
when both bones have been displaced. 

Dislocations of the Wrist. — Dislocations of the carpus 
from the bones of the forearm may be forward (Fig. 322) 
or backward (Fig. 323). The reduction in either variety 

Fig. 322. 




Dislocation of the carpus forward. (Hamilton.) 
Fig. 323. 




Dislocation of the carpus backward. (Hamilton.) 



of displacement is effected by extension from the hand and 
by pressure. After reduction of the displacement, which 
does not tend to recur, the hand and the forearm should 
be placed upon a well-padded straight splint applied to 
the palmar surface of the hand and forearm. The splint 
should be retained for ten days or two weeks. 

The lower end of the ulna may be dislocated from the 
radius forward, backward, or inward. The reduction of 
these displacements is effected by fixing the radius and 
pressing the ulna back into place. The dressing after 
reduction consists in placing the wrist-joint at rest by the 



DISLOCATIONS OF THE FINGERS. 435 

application of well-padded anterior and posterior straight 
splints. The splints should be retained for three or four 
weeks, dressings being made at intervals of two or three 
days. 

Dislocations of the Bones of the Carpus. — Displace- 
ment of the individual bones of the carpus occasionally 
takes place, the os magnum, the semilunar, and pisiform 
being the bones most usually displaced, although other 
bones of the carpus are sometimes dislocated. Reduction 
is effected by means of extension and pressure, and the 
part should afterward be dressed with a palmar splint and 
compresses. 

Dislocations of the Metacarpal Bones. — The meta- 
carpal bones may be dislocated from the carpus ; the bones 
most commonly displaced are those of the thumb and of 
the index and middle fingers ; the latter are usually dis- 
placed backward, while the metacarpal bone of the thumb 
may go either backward or forward. 

Reduction is effected by extension and pressure. The 
dressing after reduction consists in the application of a 
palmar splint to the hand and forearm and a compress 
over the displaced bone. The dressings should be retained 
for two weeks. 

Dislocations of the Fingers. — Dislocations of the 
phalanges of the fingers usually take place at the meta- 

Fig. 324. 




Backward dislocation of phalanx. Reduction by extension. (Hamilton.) 

carpo-phalangeal junction, but sometimes occur at the inter- 
phalangeal joints. The reduction is usually easily effected 
by extension (Fig. 324), or by pushing the phalanx back 



436 DISLOCATIONS. 

until it stands perpendicularly upon the metacarpal bone, 
when by strong pressure upon its base, from behind, 
forward, it is readily carried by flexion into its natural 
position. 

Where difficulty is experienced in making extension in 
the reduction of these dislocations, the ingenious apparatus 
of the late Dr. Levis (Fig. 325), or the " Indian puzzle " 
apparatus (Fig. 326), may be employed with success. 

In dislocations of the proximal phalanx of the thumb 
backward (Fig. 327) great difficulty in reduction is often 
experienced from the head of the metacarpal bone slipping 
between the heads of the short flexor of the thumb. The 

Fig. 325. 



Levis's apparatus for dislocation of the phalanges applied. 

interposition of the external sesamoid bone is considered 
by some surgeons to be the cause of difficulty in the 
reduction of this displacement. 

In this dislocation reduction is effected by firmly press- 
ing the metacarpal bone of the thumb strongly toward the 

Fig. 326. 




Extension by Indian puzzle. (Bryant.) 

palm of the hand, to relax the two portions of the short 
flexor muscle. The thumb is next extended upon the 
wrist until its tip points to the elbow. An assistant next 
places his finger behind the proximal phalanx to prevent 
its slipping backward, and by bringing the thumb down to 









DISLOCATIOXS OF THE HIP. 



437 



the flexed position the bone slips into place. It sometimes 
happens that all efforts at reduction fail, and in such cases 
it may be necessary to divide one head of the short flexor 
muscle subcutaneously or through an open wound before 
the displacement can be reduced. 




Dislocation of proximal phalanx of thumb backward. (Farabeuf.) 

The dressing of dislocations of the phalanges after re- 
duction consists in the application of splints of wood, or 
moulded splints of binders' board, or gutta-percha, to fix 
the joint, which should be retained for ten days or two 
weeks. 

Dislocations of the Hip. — The head of the femur is 
most frequently dislocated backward, downward, or up- 
ward, although it may assume other positions in excep- 
tional cases. 

Posterior or Backward Dislocations of the Head of the 
Femur. — These are either backward and upward, when 
they are described as iliac or dorsal, the bone resting upon 
the dorsum of the ilium (Fig. 328) ; or the dislocation 
may be backward, the head of the bone resting upon the 
ischiatic notch ; these are known as ischiadic dislocations, 
or dislocations of the femur, dorsal below the tendon 
(of the obturator internus), according to Bigelow (Fig. 
329). 



438 



DISLOCATIONS. 



The reduction of the posterior dislocations of the femur 
can generally be effected by manipulation. The patient 
being anaesthetized and placed upon his back, the surgeon 
grasps the leg at the ankle and knee, flexes the leg upon 
the thigh, and the thigh upon the pelvis in the position of 
adduction; he then abducts the limb and rotates it out- 



Fig. 328. 



Fig. 329. 





Backward and upward dislocation 
of femur. (Cooper.) 



Backward dislocation of femur. 
(Cooper.) 



ward, bringing it in a broad sweep across the abdo- 
men, and by bringing it down to its natural position 
the head of the bone will slip into the acetabulum (Tip;. 
330). V * 

Kocher, in posterior dislocations, recommends the fol- 
lowing manipulations : 1. The surgeon grasps the ankle 



DISLOCATIONS OF THE HIP. 439 

of the injured limb with one hand and the front of the 
knee with the other, and rotates the thigh inward, to relax 
the capsule and lift the head of the bone from the posterior 
surface of the pelvis. 2. The thigh is next flexed to 90 
degrees, preserving the existing adduction and inward 
rotation. 3. Traction is then made in the line of the 
femur, to make the capsule tense. 4. External rotation 
is then practised, which makes the posterior part of the 
capsule and Y-ligament tense, and returns the head of the 
bone to the acetabulum. 

Allis, in the reduction of dorsal dislocations, recom- 
mends that, while the patient is supine, the surgeon kneel 



Reduction of backward dislocation of the femur. (Bigelow.) 

beside him, and in the case of the right hip grasp the 
ankle with the right hand and place the bent elbow of the 
left arm beneath the knee. He then turns the bent leg 
outward by means of the ankle and lifts upward, and 
next turns the leg inward and brings the femur down in 
extension. 

Downward and Forward Dislocation of the Head of the 
Femur. — In this variety of dislocation the head of the bone 
rests upon the thyroid foramen ; this form of displacement 



440 



DISLOCATIONS. 



is sometimes spoken of as a thyroid dislocation (Fig. 

331). 

The reduction of downward and forward dislocations of 

the head of the femur is effected by flexing the leg and 

thigh and bringing the limb into a position of abduction ; 

it is then adducted and rotated inward in a broad sweep 

across the abdomen and brought 
Fig. 331. down to its natural position, 

when the head of the bone slips 
into the acetabulum (Fig. 332). 
In making these manipula- 
tions the head of the bone some- 
times slips back upon the dor- 
sum of the ilium, converting the 
downward dislocation into a 
posterior one ; if this accident 
occurs, the displacement should 

Fig. 332. 





Downward and forward disloca- 
tion of femur. (Cooper.) 



Keduction of downward and forward 
dislocation of femur. (Bigelow.) 



be reduced by making the manipulations appropriate for 
the reduction of the latter dislocation. 

Kocher, in the reduction of these dislocations, recom- 
mends the following manipulations : 1. The leg should be 
flexed upon the thigh and the thigh carried up to a right 
angle with the pelvis, maintaining abduction and external 



DISLOCATIONS OF THE HIP. 



441 



rotation, to relax the Y-ligament. 2. Traction should 
next be made in the line of the shaft of the femur, to 
render the posterior part of the capsule tense. 3. Out- 
ward rotation is then made, which, twisting the tense pos- 
terior portion of the capsule and the outer branch of the 
Y-ligament, brings the head of 
the bone upward and backward 
into the acetabulum. 

Forward and Upward Dislocation 
of the Head of the Femur. — In this 
variety of dislocation, which is 
very rare, the head of the bone 
rests upon the pubis ; this form 
of displacement is also spoken of 
as a pubic dislocation (Fig. 333). 

The reduction of forward and 
upward dislocations of the head 
of the femur is effected by much 
the same manipulation as is em- 
ployed in the reduction of down- 
ward and forward dislocations, 
except that in the pubic disloca- 
tion the flexed limb should be 
carried across the sound thigh at 
a higher point. The thigh being 
flexed, the head of the bone is 
drawn down from the pubis ; it is 
then semi-abducted and rotated in- 
ward to disengage the bone com- 
pletely. "While rotating inward 
and drawing on the thigh the 
knee should be carried inward and 
downward to its place by the side of its fellow, and the 
head of the bone will usually slip into the acetabulum. 

Kocher, in the reduction of forward and upward disloca- 
tions of the femur, recommends : 1. Traction should first 
be made in the axis of the limb, to bring the head of the 
bone over the brim of the pelvis. 2. Pressure should next 
be made with the hand upon the head of the femur, to 




Forward and upward disloca- 
tion of the femur. <,Cooper. 



442 DISLOCATIONS. 

prevent its passing upward during flexion of the thigh. 
3. The thigh should next be flexed to less than a right 
angle, to relax the Y-ligament. 4. Inward rotation is 
next made, which directs the head of the bone into the 
acetabulum. 

Anomalous Dislocations of the Head of the Femur. — These 
occasionally occur ; the head of the bone may pass directly 
upward or downward between the sciatic notch and thyroid 
foramen, or downward and backward on the body of the 
ischium, or downward and backward into the lesser sciatic 
notch, or downward, inward, and forward into the peri- 
neum. These anomalous displacements usually occur where 
there has been extensive laceration of the capsular ligament 
and Y-ligament. 

The dressing of cases after reduction of dislocations of 
the head of the femur consists in keeping the patient at 
rest in bed upon his back ; the limb should be kept at 
rest by sand bags applied to either side of the limb, or the 
knees should be tied together. The patient should be 
kept at rest for two or three weeks, and at the end of 
this time may be allowed to get out of bed and go about 
on crutches. 

Dislocations of the Patella. — The patella may be dis- 
located outward, inward, or upward, or it may be rotated 
upon its own axis. The outward dislocation is the dis- 
placement most usually seen (Fig. 334). 

Upward dislocation of the patella can only result from 
laceration of the ligamentum patellae, and the treatment 
in such cases is similar to that for fracture of the 
patella. 

The reduction of dislocations of the patella is effected 
by extending the leg upon the thigh and flexing the thigh 
upon the pelvis, to relax the quadriceps femoris muscle, 
when the patella can usually be forced back into place by 
manipulation with the fingers; in some cases alternate 
flexion and extension of the leg will accomplish the same 
result. 

The dressing after reduction of the displacement consists 
in the application of a posterior straight splint or a moulded 



DISLOCATIONS OF THE KNEE. 



443 



Fig. 334, 



binders' board or felt splint to keep the joint at rest; 
the splint should be worn for a 
week or ten days. 

Dislocations of the Knee. — 
The head of the tibia may be 
dislocated forward, backward, 
or laterally ; the latter disloca- 
tions are always incomplete, 
forward dislocation being the 
variety of displacement most 
commonly met with (Fig. 335). 

The reduction of dislocations 
of the knee is effected by exten- 
sion and counter-extension with 
forced flexion of the knee with 
pressure, aided by rocking move- 
ments. The treatment of cases 
of dislocation of the knee after 
reduction consists in fixing the 
knee-joint by the application of 
a straight posterior splint or a 
moulded splint of binders' board. 
As there is usually marked swell- 
ing following these injuries from 
violence to the joint-structures, the application of evap- 
orating lotions for a few days will be found useful. As 




Outward dislocation of the 
patella. (Duplay.) 



Fig. 335. 
Patella 




External condyle of femur 
Forward dislocation of the knee. (Bryant.) 



soon as the swelling has subsided, the limb should be put 



444 DISLOCATIONS. 

up in a plaster-of-Paris dressing, and this should be 
retained for four weeks. 

Dislocation of the Semilunar Cartilages. — The dis- 
placement here consists in the slipping forward or back- 
ward and wedging of the semilunar cartilages between the 
femoral condyles and the tibia. 

Reduction of the displaced cartilages can usually be 
effected by hyperflexion of the knee, followed by sudden 
full extension, or by alternately flexing and extending the 
joint. Excision of the displaced cartilages is sometimes 
required in cases in which they cannot be reduced by 
manipulation. 

The dressing of these cases after reduction of the dis- 
placed cartilages consists in the application of a posterior 
straight splint or a plaster-of-Paris dressing to fix the 
knee-joint ; the splint should be worn for three or 
four weeks, and if there is a tendency to redisplace- 
ment, the patient should wear a brace, or a knee-cap of 
leather or muslin, to partially fix the joint, with com- 
presses so arranged as to make pressure upon the edge 
of the joint. 

Dislocations of the Fibula. — Dislocations of the fibula 
may occur at either of its extremities, and the direction of 
the displacement may be forward, backward, or ouhvard ; 
dislocation of the head or upper extremity of the fibula 
being the most common, although all are rare forms of 
displacement. 

The reduction of dislocations of the head of the fibula 
is effected by flexing the leg upon the thigh and making 
direct pressure and extension. Dislocations of the lower 
extremity of the fibula are reduced by manipulation and 
pressure. The dressing of cases after reduction of dislo- 
cations of the fibula consists in the application of a com- 
press and moulded binders' board splint ; the dressing 
should be retained for three or four weeks. 

Dislocations of the Ankle. — Dislocations of the foot 
upon the bones of the leg result from separation of the 
articular surface of the astragalus from that of the tibia 
and fibula ; the displacement may be forward, backward 



DISLOCATIONS OF THE TARSAL BONES. 445 

(Fig. 336), or lateral (Fig. 337), the latter variety being 
often associated with fractures of the malleoli. 




Fig. 337, 




Dislocation of foot backward. 
(Bryant.) 



Dislocation of foot inward. 
(Bryant.) 



The reduction of dislocations of the ankle is effected by 
traction, combined with flexion and rotation of the ankle- 
joint, the leg being first Hexed upon the thigh to relax the 
tendo-Aehillis, and in some cases the subcutaneous division 
of this tendon is required before the reduction can be satis- 
factorily accomplished. 

The dressing of dislocations of the ankle after reduction 
consists in the application of a fracture-box or of paste- 
board splints, to fix the ankle, care being taken to see that 
the foot is fixed at a right angle to the leg, and in the 
application of evaporating lotions for a few days ; after 
the swelling has subsided a plaster-of-Paris dressing should 
be applied and retained for three or four weeks. 

Dislocations of the Tarsal Bones.— The astragalus 
may be dislocated from the bones of the leg and from the 
other tarsal bones, being thrust forward, backward, out- 
ward (Fig. 338), or inward. The reduction of dislocations 
of the astragalus outward is effected by first flexing the 
leg upon the thigh and making extension from the foot 
and rotating it at the same time, direct pressure being 



446 



DISLOCATIONS. 



Fig. 333. 



made upon the displaced bone ; in some cases subcutane- 
ous section of the tendo-Achillis has assisted materially in 
the reduction of the displaced bone. Backward disloca- 
tion of the astragalus is usually irreducible ; the patient, 
however, in many cases recovers with a useful foot. In 
cases of irreducible dislocations of the astragalus excision 
of the astragalus may ultimately be required. 

After the reduction of dislocations of the astragalus, the 
foot and leg should be put at rest in a fracture-box, or by 

means of moulded splints of 
pasteboard or felt; evaporat- 
ing lotions should also be em- 
ployed over the region of the 
injury for a few days, and when 
the swelling has subsided a plas- 
ter-of-Paris dressing should be 
applied and retained for three or 
four weeks. 

Dislocations of the calcancum 
and scaphoid upon the astraga- 
lus, or of the calcaneum upon 
the astragalus and cuboid, or 
upon the astragalus alone; of 
the scaphoid and cuboid upon 
the calcis and astragalus ; or of 
the cuboid, scaphoid, or cunei- 
form bones, are occasionally met 
with. 

Their reduction is effected by 
traction and direct pressure, and 
after this has been accomplished 
the parts should be put at rest 
by the application of a splint and compresses. 

Dislocations of the Metatarsal Bones and Phalanges 
of the Toes. — These dislocations usually result from 
crushing forces which destroy the vitality of the soft parts 
so completely that amputation is required. Their reduc- 
tion in cases of simple or uncomplicated dislocations is 
effected by traction, manipulation, and pressure. After 




Dislocation of astragalus out- 
ward. (Hamilton.) 



OLD DISLOCATIONS, 447 

reduction of the displacement the parts should be kept in 
position by the application of splints, compresses, and 
bandages. 

Old Dislocations. 

The reduction of old dislocations is attended with more 
difficulty and danger than that of recent dislocations, due 

Fig. 339. 




Reduction of old dislocation of hip by vertical extension. (Bigelow.) 

to the permanent contraction and structural changes which 
occur in the muscles and to the adhesions which form 
between the displaced bone and the parts with which it is 
in contact. The reduction of old dislocations may usually 
be accomplished by the manipulations appropriate for re- 
cent dislocations of the same variety ; but occasionally the 



448 DISLOCATIONS. 

use of more forcible extension is required, which is made 
by bands and pulleys or by vertical extension (Fig. 339). 
The first step in the reduction of old dislocations consists 
in thoroughly breaking up the adhesions which have 
been formed between the displaced bone and the surround- 
ing tissues ; this has, in some cases, resulted in the lacera- 
tion of muscles, nerves, and bloodvessels, and in fracture 
of the displaced bones or neighboring bones, so that 
the manipulations should be made with the least force 
that will accomplish the object desired. After the reduc- 
tion of old dislocations difficulty is sometimes experienced 
in maintaining the bone in its proper place, due to the 
changes which have occurred in the articular surfaces. 

If the dislocation under this method of treatment is 
found to be irreducible, and the patient suffers from great 
pain and disability, open operation is advisable. This 
consists in exposing the displaced bone and dividing the 
soft tissues which interfere with reduction or in making 
a complete or incomplete excision of the joint. 

Compound Dislocations. 

These are always grave injuries, and amputation or 
excision may be required. At the present time, under the 
modern methods of wound treatment, operative measures 
are not often required. The reduction is effected in the 
same manner as in simple dislocations of corresponding 
parts, the greatest care being taken to render the wound 
aseptic, and to keep it in this condition by the application 
of a full antiseptic dressing. After reducing the disloca- 
tion and dressing the wound some form of fixation splint 
should be applied, to fix the joint for a short time. 

Complicated Dislocations. 

In dislocations complicated by fracture near the seat of 
displacement, the displaced bone should, if possible, be 
first reduced, and this in many cases is a matter of great 
difficulty, as the fracture prevents the surgeon from using 



PATHOLOGICAL DISLOCATIONS. 449 

leverage otherwise present, in the reduction, and he has 
often to depend entirely upon pressure and manipulation 
to overcome the displacement. After reduction of the 
dislocation the fracture should be reduced and dressed. 

Dislocation complicated by rupture of the main artery 
of the limb may require, after reduction of the displace- 
ment, exposure and ligation of the vessel or amputation 
of the limb. Rupture of an important nerve-trunk com- 
plicating a dislocation may call for subsequent exposure 
and suturing of the divided nerve. 

Habitual, Pathological, and Congenital Dislocations. 

In the treatment of these varieties of dislocations after 
the reduction of the displacement by manipulation and 
pressure, much difficulty is often experienced in maintain- 
ing the reduction. To effect the latter object, the use of 
splints and bandages is employed, and also the use of many 
ingenious forms of apparatus adapted to particular dislo- 
cations. Operative treatment such as excision of a por- 
tion of the capsule of the joint or ligaments, or operation 
upon the bone to increase the capacity of the joint, may be 
practised. 

Tenotomy or myotomy is often required to prevent re- 
currence of the deformity, and continuous extension is 
also of much value in the treatment of these displace- 
ments. 

29 



OPERATIONS 



In view of the fact that at the present time in medi- 
cal schools much attention is paid to practical surgery 
— that is, operative procedures upon the cadaver — it has 
been thought advisable to introduce a very brief descrip- 
tion of a number of operations which may with advantage 
be performed upon the cadaver. Too much value cannot 
be attached to the importance of the student rendering 
himself familiar with the use of instruments and their 
manipulation in the various operative procedures, and also 
familiarizing himself with the appearance of the anatomi- 
cal parts exposed in operations. The introduction of 
sutures, the application of ligatures, the closing of wounds, 
the cutting and fitting of flaps in plastic operations, are 
procedures the practical value of which to the student 
cannot be overestimated. 



LIGATION OF ARTERIES. 

In the application of a ligature to an artery in its con- 
tinuity the surgeon should make his incision in the line 
which corresponds to the general course of the vessel, and 
he should be thoroughly familiar with the anatomy and 
with the surgical landmarks of the part. A portion of 
the artery, when possible, should be selected for the appli- 
cation of the ligature half an inch or an inch from any 
large collateral branch. The position of the incision being 

451 



452 OPERATIONS. 

selected, the surgeon steadies the skin with two fingers and 
makes an incision of the required length through it with 
a scalpel ; the superficial fascia is next picked up on a 
director, any large superficial veins which come into view 
being displaced, and divided to an equal length with the 
incision in the skin ; the deep fascia being exposed, it 
should be nicked and divided upon a director ; the inter- 
muscular space, or the edge of the muscle or muscles which 
are the guide to the vessel, should next be sought for, and 
small arteries coming from the main vessel through these 
spaces will often serve as valuable guides to the position 
of the artery. The surgeon next separates the tissues with 
the director or handle of the knife until the sheath of the 
vessel is exposed ; this is recognized by its communicated 
pulsation and by the absence of the smooth, shining 
surface and pinkish-white color which the surface of the 
artery presents. The sheath of the artery should be picked 
up with forceps and nicked with the point of the knife 
applied flatwise (Fig. 341, A) ; the incision into the sheath 
should be very limited, only sufficiently large to allow 
the aneurism needle to pass through it around the vessel ; 
extensive dissections or separations of the sheath from the 
artery should be avoided, as the nutrition of the artery at 
the point of ligature may thus be impaired, and sloughing 
and secondary hemorrhage may result. A distinct sheath 
is found only about the main arterial trunks, which is 
replaced in the smaller arteries by a layer of loose cellular 
tissue. The wall of the artery being exposed, an aneurism 
needle (Fig. 340) is passed around the vessel, threaded 
with a catgut ligature, and withdrawn (Fig. 341, B) ; the 
needle may be threaded before being passed, in which 
case the ligature is grasped with forceps and drawn 
through while the needle is withdrawn. The best ma- 
terial for ligatures is silk or carefully prepared chromi- 
cized catgut. The needle should be passed away from 
important structures, such as accompanying veins and 
nerves. 

Before the ligature is tied the surgeon should satisfy 
himself that the ligature when tied will control the circu- 



LIGATIOX OF THE INNOMINATE ARTE BY 



453 



lation in the artery below its point of application, by 
placing the tip of his linger upon the vessel and drawing 
upon the ends of the ligature, so as to occlude the vessel 
at the point of application. Being satisfied as to this 
point, the ligature is tied with a reef-knot, or a surgeon's 
knot and reef-knot combined, and the ends of the ligature 
are cut short in the wound (Fig. 341, C). 



Fig. 340. 



Fig. 341. 





Aneurism needle. 



A, opening sheath : B. passing ligature around the 
vessel ; C, tying^the artery. 



Some authorities recommend the application of two liga- 
tures a short distance apart in the ligation of vessels in 
their continuity, and a division of the vessel between them. 
so that both ends may retract into the cellular sheath. 



Ligation of Special Arteries. 

Ligation of the Innominate Artery. — The innominate 
artery lies immediately behind the sterno-clavicular artic- 
ulation, and is in relation in front with the innominate 



454 OPERATIONS. 

veins and pneumogastric nerve, on the inner side with the 
trachea, on the outer side and behind with the pleura. 

The incision is a V-shaped incision, each branch of 
which is two and a half or three inches in length, one of 
which lies over the anterior edge of the sterno-cleido- 
mastoid muscle and the other parallel to and a little above 
the clavicle (Fig. 342, A). The incisions are carried down 
to the superficial fascia and a flap is dissected up. If the 
anterior jugular vein is met with, it should be displaced. 




Lines of incision for — A, innominate artery ; B, right subclavian artery ; 
C, left subclavian artery ; D, vertebral or inferior thyroid artery ; E, axillary 
artery below clavicle. (Stimson.) 

The sternal and clavicular attachments of the sterno- 
cleido-mastoid are next divided upon a director half an 
inch above the bone. The sterno-thyroid and sterno- 
hyoid muscles and the middle cervical fascia are then ex- 
posed, covered by the thyroid veins. The outer fibres of 
the sterno-hyoid and sterno-thyroid muscles are next 
divided, the thyroid vein being held aside, when upon 
tearing through the fascia with a director the common 
carotid artery is exposed and traced down to the innomi- 
nate artery ; the innominate veins are pressed against the 
sternum with the finger, and the artery is separated from 






LIGATION OF THE SUBCLAVIAN ARTERY. 455 

its sheath about half an inch below its bifurcation, and the 
aneurism needle is passed around the vessel from the outer 
side, so as to avoid the vein, pneumogastric nerve, and 
pleura. 

Ligation of the Subclavian Artery. — This artery may 
be tied at three points ; in its first portion, between the 
trachea and scaleni muscles ; in its second portion, behind 
the scaleni muscles ; and in its third portion, external to 
the scaleni muscles. 

The left subclavian artery in its first portion is larger 
and more vertical in its direction than the right subclavian, 
and is situated more posteriorly. From the difficulty in 
exposing this portion, and from the possibility of injuring 
the thoracic duct, the ligation of this artery in its first 
portion has been seldom attempted. 

The incision for the first portion of the subclavian artery 
is the same as that for the innominate (Fig. 342, A), and 
the ligature is passed from the outer side, the pneumogas- 
tric and phrenic nerves being pressed inward toward the 
carotid artery. 

The right and left subclavian arteries are also seldom 
tied in their second portions — that is, behind the scaleni 
muscles — but are frequently tied in their third portions — 
that is, external to the scaleni muscles. 

The incision for the second portion of the subclavian 
artery begins an inch external to the sterno-clavicular 
articulation, half an inch above and parallel to the clav- 
icle, and is three or four inches in length (Fig. 342, B or 
C). The steps of the operation are the same as for liga- 
tion of the third portion, and when the scalenus anticus 
muscle has been exposed, it is divided upon a director ; the 
phrenic nerve, which lies upon its anterior aspect, is to be 
avoided. 

The incision for the third portion of the subclavian artery 
is the same as for the second portion (Fig. 342, B or C). 
The skin and platysma being divided, the external jugular 
vein is exposed and drawn to one side or divided between 
two ligatures ; the superficial fascia is next divided upon a 
director ; the posterior belly of the omo-hyoid muscle is 



456 



OPERATIONS. 



next found and drawn upward and outward ; the outer 
border of the scalenus anticus is next felt for and followed 
down to the tubercle of the first rib — the artery lies against 
this, between it and the lowest bundle of the brachial 
plexus. The artery is next denuded with the director, 
and the needle is passed from below, care being taken not 



Fig. 343. 



o-hyoid 




Ligation of subclavian and lingual arteries. (Bryant.) 

to include the lowest bundle of the brachial plexus in the 
ligature (Fig. 343). 

Ligation of the Vertebral Artery. — The incision for 
the ligation of the vertebral artery is three or three and a 
half inches in length, parallel with the anterior edge of 
the sterno-cleido-mastoid muscle, ending- an inch above 



LIGATION OF THE COMMON CAROTID ARTERY. 457 

the clavicle (Fig. 342, D). The anterior edge of the 
sterno-eleido-mastoid being exposed, the middle cervical 
fascia is divided and the carotid artery and jugular vein 
are exposed and drawn inward. The gap between the 
longus colli muscle and the scalenus anticus muscle is 
next felt for about an inch below the carotid tubercle ; the 
fascia covering it is next torn through and the muscles are 
separated and the vertebral vein comes into view. When 
this vein is held aside the vertebral artery is exposed, and 
the ligature is then passed around it. 

Ligation of the Inferior Thyroid Artery. — The in- 
cision for the inferior thyroid artery is the same as that for 
the vertebral artery (Fig. 342, I)). The anterior edge of 
the sterno-cleido-mastoid muscle being exposed, it is drawn 
outward, the middle cervical fascia is next divided, and the 
carotid artery and internal jugular vein are drawn outward 
with a retractor. The head being flexed slightly, the sur- 
geon feels for the carotid tubercle, and then separates the 
cellular tissue with a director, and the artery should be 
found below the carotid tubercle. The needle should be 
passed between the artery and vein. 

Ligation of the Internal Mammary Artery. — The 
incision, a vertical one, two and a half inches in length, 
commences at the lower border of the clavicle, parallel 
with and three lines external to the margin of the ster- 
num. Divide the skin and superficial fascia and expose 
the fibres of the great pectoral muscle, the external inter- 
costal aponeurosis, and the muscular fibres of the internal 
intercostal muscle. Raise the fasciculi of the latter mus- 
cle upon a director and divide them, and the vessel will 
be exposed. The internal mammary artery is not often 
tied below the fourth intercostal space. 

Ligation of the Common Carotid Artery. — The point 
of election for the ligation of the common carotid artery 
is just above the omo-hvoid muscle, about three-quarters 
of an inch below the bifurcation of the vessel, which takes 
place at a point on a line with the upper border of the 
thyroid cartilage. 

The incision for the common cartoid artery is three 



458 



OPERATIONS. 
Fig. 344. 




Line of incision for common carotid artery at point of election. (Stimson.) 

Fig. 345. 




Relations of the left common carotid artery above the omo-hvoid muscle. 
(Esmarch.) 

inches in length along the anterior border of the sterno- 
cleido-mastoid muscle, the centre of which corresponds 
with the crico-thyroid space (Fig. 344). 






LIGATION OF THE EXTERNAL CAROTID ARTERY. 459 

Divide the skin, platysma, cellular tissue, and aponeu- 
rosis, avoiding the superficial veins, and expose the ante- 
rior edge of the sterno-clei do-mast oid ; seek for the inter- 
space between this muscle and the sterno-hyoid and 
stern o-thyroid muscles, draw the latter muscles inward, 
and the artery will be exposed with the jugular vein exter- 
nal to it ; the descendens noni nerve lying upon its sheath 
should be displaced outward. The sheath is next picked 
up and opened and the artery is separated from it with 
a director; the artery lies internally, the internal jugular 
vein externally and somewhat more superficial, and the 
pneumogastric nerve lies between the two, and is more 
deeply placed. The sympathetic nerve is posterior to the 
vessel external to the sheath. The needle is passed from 
without inward, care being taken to avoid injury of the 
vein and nerve (Fig. 345). 

Ligation of the External Carotid Artery. — The in- 
cision for the ligation of the external carotid artery is over 

Fig. 346. 



Lines of incision for— A, lingual artery : B, external and internal carotid arte, 
ries; C, occipital artery ; D, temporal artery ; E, facial artery. (Stimson.) 

the inner edge of the sterno-cleido-mastoid muscle from 
the angle of the jaw to a point corresponding to the mid^ 



460 OPERATIONS. 

die of the thyroid cartilage (Fig. 346, B). The skin, pla- 
tysma, and cellular tissue being divided, the external 
jugular vein is drawn aside when encountered ; the deep 
fascia being opened, the facial and lingual veins will be 
exposed, which should be draw r n to one side ; the artery is 
next exposed, covered by the hypoglossal nerve and the 
stylo-hyoid and digastric muscles. The vessel should 
next be isolated from the internal carotid artery and inter- 
nal jugular vein, both of which lie along its outer side. 
The needle should be passed from without inward. 

Ligation of the Internal Carotid Artery. — The in- 
cision is the same as for the external carotid artery (Fig. 
346, B) ; the vessel is external to the external carotid 
artery, and in passing the needle the point should be 
directed away from the internal jugular vein — that is, 
from without inward. 

Ligation of the Superior Thyroid Artery. — The in- 
cision is about three inches in length along the anterior 
border of the stqrno-cleido-mastoid muscle, starting a little 
lower down than that for the external carotid artery. The 
skin, superficial fascia, platysma, aud deep fascia being 
divided, the cellular tissue in the sulcus between the upper 
portion of the larynx and the great vessels of the neck 
should be broken up with the director and the vessel ex- 
posed. The needle should be passed around the vessel 
from above downward. 

Ligation of the Lingual Artery. — The incision is a 
curved one two inches long, its concavity directed upward 
from the anterior edge of the sterno-cleido-mastoid muscle, 
half an inch above the great horn of the hyoid bone, to a 
point one inch within the median line of the neck (Fig. 
346, A). Divide the skin and platysma, displacing the 
superficial veins, and open the deep fascia, when the sub- 
maxillary gland will be exposed ; this is displaced upward 
with the handle of the knife, when the tendon of the digas- 
tric muscle attached to the hyoid bone, and the hypo- 
glossal nerve will be exposed ; next divide the fibres of the 
hyoglossus muscle midway between the hypoglossal nerve 
and the hyoid bone, and the lingual artery will be exposed 



LIGATION OF THE TEMPORAL ARTERY. 461 

(Fig. 347). The needle should be passed around the 
vessel from above downward, in order to avoid the 
nerve. 

Fig. 347. 




Relations of the lingual artery. E.-makch.; 

Ligation of the Facial Artery. — The facial artery 
passes over the inferior maxilla just in front of the ante- 
rior edge of the masseter muscle, and is accompanied by 
the facial vein, which lies nearer to the muscle. 

The incision is either a horizontal one along the lower 
border of the maxilla or a vertical one an inch in length 
(Fig. 346, E . The skin, subcutaneous tissue, and fascia 
being divided, the artery is exposed ; the needle should 
be passed around the vessel away from the vein. 

Ligation of the Occipital Artery. — The incision istwo 
inches in length, starting from a point half an inch below 
and in front of the apex of the mastoid process, and carried 
obliquely backward, parallel to the border of this process 
(Fig. 346, C). Divide the skin and fascia and expose the 
insertion of the sterno-cleido-mastoid muscle, which is also 
divided, and the aponeurosis of the splenitis is exposed ; 
this is also opened and the digastric groove is felt for, and 
when the belly of the digastric muscle is exposed the artery 
is brought into view by separating the cellular tissue in the 
anterior angle of the wound with a director (Fig. 348). 

Ligation of the Temporal Artery. — The incision is a 



462 



OPERATIONS. 



transverse one, one inch in length, starting from the tragus 
of the ear forward over the zygomatic arch (Fig. 346, D), 
or a vertical one of the same length a little in front of the 
tragus of the ear. 

Divide the skin and expose the subcutaneous cellular 
tissue, which in this region is very dense and fibrous. 
This tissue should be broken up with a director, and the 
artery should be found in it about a quarter of an inch in 
front of the ear (Fig. 349). The temporal vein accom- 
panies the artery and lies nearer to the ear, and in some 
cases the auriculotemporal nerve is in close relation to 



Fig. 348. 



Fig. 349. 





Ligation of the occipital artery. 
(Skey.) 



Ligation of the temporal artery. 
(Skey.) 



the artery. The needle should be passed from behind 
forward. 

Ligation of the Axillary Artery. — The axillary artery 
extends from the middle of the clavicle to the insertion of 
the teres major into the humerus ; the axillary vein lies 
upon the inner side and in front of the artery. The axil- 
lary artery is tied either in its upper portion, just below 
the clavicle, or at its lower portion in the axilla. 

Axillary Artery below the Clavicle. — The incision is four 
inches in length from the summit of the coracoid process 
inward a short distance below the clavicle (Fig. 342, E), 
or an incision three inches in length, commencing at a 



LIGATION OF TEE AXILLARY ARTERY. 463 

point one-half an inch from the sterno-clavicular articu- 
lation, and carried obliquely downward toward the axilla. 

The skin and subcutaneous tissue having been divided, 
the deep fascia is exposed and opened, and the axillary 
artery may be reached by following the intermuscular 
space between the sternal and clavicular fibres of the pec- 
toralis major which leads upward toward the clavicle and 
to the pectoralis minor ; or the fibres of the pectoralis 
major being exposed, are cut through and the costo-cora- 
coid membrane is next torn through with a director, care 
being taken to avoid injury of the cephalic vein at the 
outer portion of the w T ound ; the pectoralis minor is now 
seen, and after separating the cellular tissue with a director 
the axillary vein is seen crossing from the upper edge of 
the muscle to the clavicle ; the vein almost completely 
covers the artery, which is exposed by drawing the vein 
inward. The needle is passed around the artery from 
within outward. 

Axillary Artery in the Axilla. — The incision is two and 
a half inches long, started at the upper part of the axilla 

Fig. 350. 



A. Incision for axillary artery in axilla. B. Incision for brachial artery. 
(Stimson.) 

and carried down the arm at the edge of the coraco- 
brachialis muscle (Fig. 350, A). The skin only is divided 
in the first incision. The deep fascia is then picked up 
and divided upon a director. As soon as the fibres of the 
inner border of the coraco-brachialis muscle are exposed 
and held aside by a retractor, the operator will see the 



464 



OPERATIONS. 



median nerve, the musculocutaneous nerve, and the axil- 
lary artery. To the inner side of the artery are the axil- 

Fig. 351. 




Relations of right axillary artery in axilla. (Esmarch.) 
Fig. 352. 




Relations of right brachial artery at middle of arm. (Esmarch.) 

lary vein, ulnar and internal cutaneous nerves (Fig. 351). 
The needle should be passed around the artery from the 
vein toward the coraco-brachialis muscle. 



LIGATION OF THE RADIAL ARTERY. 465 

Ligation of the Brachial Artery. — The incision is 
three inches long at the middle of the arm, on a line corre- 
sponding to the inner edge of the biceps muscle (Fig. 
350, B). The skin and cellular tissue having been divided, 
care being taken not to injure the basilic vein, which should 
be displaced posteriorly, the deep fascia is next cut through 
and the fibres of the biceps muscle are exposed (Fig. 352) ; 
this muscle should be drawn forward and the sheath of 
the vessels enclosing the artery, veins, and median nerve 
exposed ; the sheath having been opened, the median nerve 
is pressed aside and the artery is separated from its veins, 
and the needle is passed from the side of the nerve around 
the vessel. In ligating the brachial artery the occasional 
high division of the vessel must be borne in mind. 

Brachial Artery at Bend of the Elbow. — The incision is 
two inches in length, along the inner border of the tendon 

Fig. 353. 

Tendinous aponeurosis 

divided. .^- 




Ligation of the brachial artery at the bend of the elbow. (Bryant.) 

of the biceps muscle. Divide the skin, superficial fascia, 
and the bicipital aponeurosis, under which the artery will 
be exposed, resting upon the brachialis anticus muscle 
(Fig. 353). The median nerve is to the inner side and 
some distance from the artery. The needle should be 
passed around the vessel, after isolating the veins, from 
within outward. 

Ligation of the Radial Artery. — The radial artery 
extends in a straight line from a point half an inch below 

30 



46(3 



OPERA TIONS. 



the centre of the fold of the elbow to the inner side of the 
styloid process of the radius. 

The radial artery may be tied at its upper, middle, or 
lower third, or at the root of the thumb. 



Fig. 354. 



Fig. 355. 





Relations of right radial artery in the upper 
third of the forearm. (Esmarch.) 

Fig. 356. 




Line of incision for— .4. Radial artery 
in upper third. B. Radial artery in 
lower third. C. Ulnar artery in upper 
third. D. Ulnar artery in lower third. Relations of right radial artery above 
(Stimso>\) the wrist. (Esmarch:.) 



Radial Artery in the Upper Third of the Forearm. — The 
incision for the radial artery at its upper third is two and 
a half inches in length on a line drawn from the middle 
of the bend of the elbow to the uluar side of the styloid 
process of the radius ; the incision should begin one and a 
half inches below the bend of the elbow (Fig. 354, .4). 
Divide the skin and superficial fascia, avoiding the super- 



LIGATION OF THE ULNAE ARTERY. 467 

ficial veins. When the deep fascia is exposed, find the 
edge of the supinator longus muscle and divide the apo- 
neurosis along its ulnar side, and expose the fibres of the 
pronator radii teres muscle. The vessel lies in the inter- 
space between these muscles surrounded by adipose tissue, 
and upon being exposed the veins should be isolated and 
the needle passed from without inward. The radial nerve 
lies so far external to the artery that it is not often ex- 
posed in the operation (Fig. 355). 

Radial Artery in the Middle Third of the Forearm. — The 
incision is two inches in length, following the same line as 
that for the upper third of the artery. After dividing 
the skin, superficial and deep fascia, the artery is found 
in the interspace between the flexor carpi radialis on the 
inner side and the supinator longus on the outer side ; 
the radial nerve at this part of the arm is in close relation 
with the vessel to the radial side, and the needle should 
be passed around the artery from without inward. 

Radial Artery in the Lower Third of the Forearm. — The 
incision is two inches in length, following the same line 
(Fig. 354, B), ending one inch above the wrist. The 
skin, superficial and deep fascia being divided, the artery 
will be found between the tendon of the flexor carpi 
radialis on the inner side and the tendon of the supinator 
longus on the outer side (Fig. 356). The veins being 
separated, the needle may be passed in either direction. 

Radial Artery at the Root of the Thumb. — The radial 
artery may also be tied at the root of the thumb. The 
incision is one inch in length between the tendons of 
the extensor ossis metacarpi pollicis and extensor primi 
internodii pollicis on the outer side, and the tendon of the 
extensor secundi internodii pollicis on the inner side. The 
skin and superficial fascia being divided and the radial 
vein being displaced, the deep fascia is opened and the 
artery is exposed at the bottom of the wound ; the needle 
may be passed in either direction. 

Ligation of the Ulnar Artery. — The ulnar artery is 
tied at the junction of the upper and middle thirds of the 
forearm and at the lower third. 



468 



OPERATIONS. 



Ulnar Artery at the Junction of the Upper and Middle 
Thirds of the Forearm. — The incision is three inches in 
length, starting four inches below the internal condyle of 
the humerus on a line passing from the internal condyle of 
the humerus to the outer border of the pisiform bone 
(Fig. 354, C). Divide the skin and superficial fascia, 
and when the deep fascia has been exposed and the in- 
terspace between the flexor carpi ulnaris and the flexor 
sublimis digitorum appears, enter this interspace and raise 
the flexor sublimis digitorum and work transversely across 

the arm. The artery will 
Fig. 357. be found resting upon the 

deep flexor, with the ulnar 

Fig. 358. 




Relations of the right ulnar arterv at upper Relations of the right ulnar artery 
third of the forearm. (Esmarch.) above the wrist. (Esmarch.) 

nerve to the ulnar side. The needle should be passed 
from the nerve around the artery (Fig. 357). 

Ulnar Artery in the Lower Third of the Forearm. — The 
incision is two inches in length, a little to the radial side 
of the tendon of the flexor carpi ulnaris, which is attached 
to the pisiform bone, ending an inch above the w T rist (Fig. 
354, D). Divide the skin and superficial fascia and open 
the deep fascia ; the artery will be exposed with its 
accompanying veins, between the tendons of the flexor 
carpi ulnaris and flexor sublimis digitorum, the ulnar nerve 
being to the ulnar side of the vessel. The needle should be 
passed from within outward to avoid the nerve (Fig. 358). 






LIGATION OF THE COMMON ILIAC ARTERY. 469 

Ligation of the Interosseous Artery.—The incision is 
similar to that employed in the ligation of the ulnar arterv 
in its upper third. 

Ligation of the Abdominal Aorta. — The indsum is in 
the linea alba from a point three inches above the umbili- 
cus to a point three inches below it. The superficial 
structures being divided, the peritoneum is opened upon a 
director, and the intestines are pressed aside and the aorta 
is exposed, covered by peritoneum, with the filaments of 
the sympathetic nerve resting upon it and the vena cava 
to the right side. Tear through the peritoneum and pass 
the needle from right to left around the vessel. After 
tying the ligature the ends should be cut short and the 
external wound should be closed as in the ordinary lapar- 
otomy wound. 

The vessel may also be exposed by an incision along 
the anterior border of the quadratus lumborum muscle, 
from the last rib to the crest of the ilium. The skin, 
lumbar muscles, and fascia transversalis being divided, 
the wound is held open with blunt hooks, so that the 
retroperitoneal space is exposed and the aorta brought 
into view. The vessel being separated from the vena cava 
and nerves, the needle is passed around it and the ligature 
applied. 

Ligation of the Common Iliac Artery. — The aorta 
divides into the two common iliac arteries on the left 
side of the fourth lumbar vertebra, and these arteries are 
usually about two inches in length, and bifurcate opposite 
the sacro-iliac synchondrosis to form the internal and 
external iliac arteries ; the length of the common iliac 
artery, however, may vary considerably, being three or 
four inches in some cases. 

The incision for ligation of the common iliac artery is 
four to six inches in length, beginning one-half inch above 
the middle of Poupart's ligament, and is carried outward, 
curving upward after passing the anterior superior spine 
of the ilium (Fig. 359, A). 

Divide the skin, superficial fascia, and aponeurosis of 
the external oblique muscle, and then divide the fibres 



470 



OPERATIONS. 



of the internal oblique and transversalis muscles upon a 
director and expose the transversalis fascia. This is 
opened at the lower part of the wound, and the finger 
is introduced and the peritoneum pressed back ; the 
opening in the transversalis fascia is next enlarged, and 
the peritoneum is carefully drawn inward and upward 
with the fingers toward the inner edge of the wound. 
The operator next feels for the external iliac artery, and 
passes the finger along this until the common iliac artery 

is reached. The loose cellular 
tissue in which it is imbedded 
is next separated, and the nee- 
dle is passed from within out- 
ward, to avoid the common iliac 
vein (Fig. 360), which on the 
left side lies on the inner side 
of the artery, and on the right 
side lies behind the artery. The 
ureter generally remains attached 
to the peritoneum ; if not, it is 
seen crossing the bifurcation of 
the common iliac with the genito- 
crural nerve ; care should be 
taken to avoid injury of these 
structures. 

Transperitoneal Method. — The 
common iliac artery may also be 
exposed and tied by an incision made over the artery 
through the abdominal wall opening the peritoneal cav- 
ity : the vessel being tied, the ends of the ligature are 
cut short, and the external wound is closed in the same 
manner as that resulting from exposure of the abdom- 
inal aorta by incision through the peritoneum. 

Ligation of the Internal Iliac Artery. — The incision 
is in the same line as for the common iliac artery, but it 
need not be quite so long (Fig. 359, A). The perito- 
neum being exposed, it is pushed upward and inw r ard, 
and the internal iliac artery is exposed. The vessel 
is carefully isolated from the vein, which lies behind and 




Lines of incision for— A. Com- 
mon iliac artery. B. External 
iliac artery. C. Femoral artery 
in Scarpa's triangle. (Stimson.) 



LIGATION OF THE EXTERNAL ILIAC ARTERY, 471 

on the inner side, and the needle is passed from within 
outward. 

The transperitoneal method may also be employed in 
exposing and ligating this vessel. 

Ligation of the External Iliac Artery. — The incision 
is three or four inches in length, half an inch above the 
middle of Poupart's ligament, made at first parallel to it 

Fig. 3G0. 




Ligation of the common iliac artery. (Liston.) 

and then curved upward (Fig. 359, B). The tissues of the 
abdominal wall being divided and the peritoneum exposed, 
it is pushed upward and inward in the same manner, as 
for exposure of the common iliac artery. The artery lies 
at the inner border of the psoas muscle, the vein on its 
inner side and the anterior crural nerve covered by the 
iliac fascia on the outer side; the genito-crural nerve 
passes obliquely across the artery (Fig. 361). The needle 
should be passed from within outward. 

The transperitoneal method may also be employed in 
ligating this vessel. 



472 



OPERATIONS. 



Ligation of the Gluteal Artery. The incision is three 
or four inches in length, from the posterior superior spinous 
process of the ilium to a point midway between the tuber 
ischii and the great trochanter (Fig. 362, A). After divis- 
ion of the skin and fascia, the fibres of the gluteus rnaxi- 
mus muscle are separated and held apart, the deep 
fascia is divided, and the artery should then be sought for 
above the pyriformis muscle at the upper border of the 



Fig. 361. 




Relations of the right external iliae artery. (Esmarch.) 

great sacro-sciatic notch. It is accompanied by large 
veins, injury to which should be avoided in exposing the 
artery and passing the needle. 

Ligation of the Sciatic and Internal Pudic Arteries. 
— The incision is three or four inches in length, a little lower 
than that employed for exposure of the gluteal artery (Fig. 
362, B). Divide the skin, superficial fascia, and fibres of 
the gluteus maximus muscle and deep fascia, and search 
for the vessels as they leave the great sciatic notch at the 
lower edge of the pyriformis muscle. The internal pudic 
artery enters the pelvis through the lesser sciatic notch, 
lying on the inner side of the sciatic artery during its pas- 



LIGATION OF THE FEMORAL ARTERY. 



473 



sage over the spine of the ischium. The vessels are isolated 
and the needle is passed so as to avoid injury of the veins. 

Ligation of the Femoral Artery. — The femoral artery 
may be ligated just below Poupart's ligament, at the apex 
of Scarpa's triangle, at the middle of the thigh, or in 
Hunter's canal. 

Femoral Artery below Poupart's Ligament. — The incision 
begins midway between the anterior superior spinous 



Fig. 362. 




Lines for— A. Gluteal artery. B. Sciatic and internal pudic arteries. (Stimson.) 



process of the ilium and the symphysis pubis, one-fourth 
of an inch above Poupart's ligament, and extends two 
inches downward. Divide the skin and superficial fascia 
and the deep fascia so as to expose the sheath of the 
vessels ; open this one-half an inch below Poupart's liga- 
ment and isolate the femoral artery from the femoral vein 
which lies to the inner side ; the anterior crural nerve lies 
to the outer side. Pass the needle from within outward 
(Fig. 363). 

Femoral Artery at the Apex of Scarpa's Triangle. — The 
incision is three inches long, the centre of which should be 



474 



OPERATIONS. 



Fig. 363. 



a. little above the point where the sartorius muscle crosses 
a line drawn from the middle of Poupart's ligament to 
the inner condyle of the femur (Fig. 364). Divide the 
skin, superficial and deep fascia, avoiding the internal 
saphenous vein, and expose the edge of the sartorius 
muscle, which may be recognized by the direction of its 
fibres. This muscle is drawn outward and the sheath of 
the vessels is exposed and opened; the vein lies on the 
inner side and somewhat behind the artery, and the long 
saphenous nerve is on the outer side 
(Fig. 365). Pass the needle from 
within outward. 

Femoral Artery in the Middle of 
the Thigh. — The incision is in the 
line above mentioned, its centre 
being a little above the middle of 
the thigh. Divide the skin, super- 
ficial and deep fascia, and expose 
the sartorius muscle, which is drawn 
outward after the leg has been 
flexed ; the sheath of the vessels is 
exposed and opened; the long sa- 
phenous nerve lies upon the artery 
and the femoral vein lies behind the 
artery ; the saphenous vein lies more 
superficially and internal to the ves- 
sel. Pass the needle from within 
outward (Fig. 366). 

Femoral Artery in Hunter's Canal. 
— The incision is three inches in 
length along the tendon of the adductor magnus, the centre 
of which is at the junction of the lower and middle thirds 
of the thigh (Fig. 364). Divide the skin, superficial and 
deep fascia, care being taken not to injure the internal 
saphenous vein, which should be displaced, and expose 
the sartorius muscle, which should be displaced down- 
ward, and expose the aponeurosis which forms the ante- 
rior wall of the vascular canal ; this should be opened 
upon a director, and the artery uncovered and separated 




Relations of the right fem- 
oral artery below Poupart's 
ligament." (Esmabch.) 



_.•, _ 



LIGATION OF THE POPLITEAL ARTERY. 475 

from the vein which lies upon the outer side. The needle 
is passed from within outward. 
Ligation of the Popliteal Artery.— The incision is 



Fig. 364. 




Lines of incision for the femoral artery. (Stimson.) 
Fig. 365. Fig. 366. 





Relations of the right femoral 
artery at the apex of Scarpa's 
triangle. ^Esmarch.) 



Relations of the right femoral ar- 
tery in the middle of the thigh. 
(Esmarch.) 



three or four inches in length, along the external border 
of the semi-membranosus muscle. Divide the skin and 



476 



OPERATIONS. 



superficial fascia, taking care not to injure the saphenous 
vein, and open the deep fascia. The edges of the wound 
being held apart, the adipose tissue is broken up with a 
director, and the internal popliteal nerve will first be ex- 
posed, and the vein next — both external to the artery 
(Fig. 367). The artery is isolated and the needle passed 
from without inward. 



Fig. 367. 



Fig. 368. 





Relations of the right popliteal artery. 
(Esmarch.) 



Ligation of the anterior tibial artery 
at its upper third. (Stimson.) 



Ligation of the Anterior Tibial Artery.— The ante- 
rior tibial artery may be tied in the upper, middle, and 
lower thirds of the leg ; the general direction of the artery 
corresponds with a line drawn from the middle of the 
space between the head of the fibula and the tubercle of 
the tibia to the middle of the anterior intermalleolar space. 

Anterior Tibial Artery in the Upper Third of the Leg.— 
The incision is two and a half to three inches in length, 
one and one-fourth inches external to the spine of the 
tibia. Divide the skin and superficial fascia, and when 



LIGATION OF THE POSTERIOR TIBIAL ARTERY. 477 

the deep fascia is exposed, open it on a line corresponding 
to the intermuscular space between the tibialis anticus and 
the extensor longus digitorura muscles. Separate the 
muscles and work down in this interspace until the artery 
is found with a vein on either side of it, and the anterior 
tibial nerve externally (Fig. 368). The needle should be 
passed from without inward after isolating the veins. 

Anterior Tibial Artery at its Middle Third. — The incision 
is three inches in length in the same line as that for the 
upper portion of the vessel. After dividing the skin, 
superficial and deep fascia, the interspace between the tib- 
ialis anticus and the extensor longus digitorum muscles is 
opened, when a third muscle comes into view, the extensor 
proprius pollicis. The artery lies between the extensor 
proprius pollicis and the tibialis anticus muscles; and the 
anterior tibial nerve is to the outer side. The veins should 
be isolated and the needle passed from without inward. 

Anterior Tibial Artery in its Lower Third. — The incision 
is two inches in length, beginning three inches above the 
ankle-joint on the line of the artery. Divide the skin, 
superficial and deep fascia, and seek for the tendon of the 
extensor proprius pollicis muscle, the second tendon from 
the tibia. The artery is found in the interspace between 
this tendon and the tendon of the extensor longus digito- 
rum muscle, the nerve being to the outer side. The veins 
are isolated from the artery, and the needle is passed from 
without inward. 

Ligation of the Dorsalis Pedis Artery. — The incision 
is one inch in length on a line drawn from the middle of 
the anterior inter malleolar space to a point midway be- 
tween the extremities of the first two metatarsal bones or 
along the outer border of the tendon of the extensor pro- 
prius pollicis. Divide the skin, superficial and deep fascia, 
and the artery will be found lying next to the inner tendon 
of the short extensor muscle of the toes (Fig. 369). The 
nerve is to the outer side. After separating the veins the 
needle is passed from without inward. 

Ligation of the Posterior Tibial Artery. — The course 
of the posterior tibial artery is indicated by a line drawn 



478 



OPERATIONS. 



from the middle of the popliteal space to a point midway 
between the tendo-Achillis and the internal malleolus of 
the tibia. 

The posterior tibial artery may be ligated in its upper, 
middle, and lower thirds. 

Posterior Tibial Artery at its Upper Third. — The incision 
is three and a half inches in length, one-half inch from 
the inner edge of the tibia, beginning two inches from the 
upper edge of the bone (Fig. 370). Divide the skin and 



Fig. 369. 



Extensor 

brevis digitorum 

muscle. 




Tendon of 
extensor 
proprius 
pollicis. 




Ligation of the dorsalis pedis artery. (Bryant.) 



Lines of incision for the 
posterior tibial artery. 
(Stimson.) 



superficial fascia, avoiding large superficial veins; next 
open the deep fascia and detach the origin of the soleus 
muscle from the tibia, and on raising it the under surface 
will present a white, shining sheath of tendinous material, 
beneath which will be seen a layer of fascia covering the 



LIGATION OF THE POSTERIOR TIBIAL ARTERY. 479 

tibialis posticus muscle. If search is made toward the 
middle of the leg the artery will be found covered by the 
intermuscular fascia, the nerve being to the outer side. 
The needle is passed from without inward after the veins 
have been separated from the artery (Fig. 371). 

Fig. 371. 




Relations of the right posterior tibial artery in its upper third. (Esmakch.) 



Posterior Tibial Artery at its Middle Third. — The incision 
is two and a half inches in length, parallel with the inner 
edge of the tibia and half an inch from its border. Divide 
the skin, superficial and deep fascia, and the inner edge 
of the soleus will be exposed ; press this outward, when the 
artery with its veins will be exposed, also the posterior 
tibial nerve to the outer side. Pass the needle from with- 
out inward after separating the veins. 

Posterior Tibial Artery behind the Inner Malleolus. — The 
incision is a curved one two inches in length, midway be- 
tween the tendo-Achillis and the internal malleolus (Fig. 



480 



OPERATIONS. 



370). Divide the skin and superficial fascia, then lift 
the deep fascia upon a director and open it freely, when 
the artery will be exposed, with the tendons of the tibialis 
posticus and flexor longus digitorura muscles on the inner 
side and the posterior tibial nerve and the tendon of the 



Fig. 372. 



// u 




Ligation of the posterior tibial artery behind the inner malleolus. (Bryant.) 

flexor longus pollicis muscle on the outer side (Fig. 372). 
After separating the veins from the artery the needle 
should be passed from without inward. 



PAET VII. 

AMPUTATIONS. 



The term amputation is now generally applied to the 
removal of a limb, and this may be effected through the 
bones, when the operation is spoken of as an amputation 
in the continuity of the limb ; or it may be removed 
through its joints, when it is known as an amputation 
in the contiguity or a disarticulation. 

Methods of Amputating. 

Amputations may be performed by the circular, modi- 
fied circular or ovalj elliptical, and transfixion methods. 
TeaJe's method by rectangular flaps is also employed. 

Circular Method. — In performing an amputation by 

this method the incision of the skin is made at a distance 
below the point where the bone is to be divided. An 
assistant grasps the limb and draws the skin evenly and 
firmly toward the root of the part, and the surgeon passes 
the heel of the knife well into the tissues and makes a cir- 
cular sweep around the limb, completing the division of 
the skin and cellular tissue with one motion of the knife 
(Fig. 373). 

The second incision in an amputation by the circular 
method consist-, after retraction of the skin, in making a 
circular cut through all of the tissues down to the bone 
(Fig. 374). 

The third step in an amputation by this method consists, 

31 481 



482 



AMPUTATIONS. 
Fig. 373. 




Amputation by circular method. (Druitt.) 

after retracting the skin and muscles and holding them 
back by a retractor, in the division of the bone with a saw. 

Fig. 374. 




Division of muscles in circular amputation. (Smith.) 

Transfixion Method. — This is a variety of the flap 
method, the flaps being cut from within outward ; they may 
be lateral or antero-posterior. In amputating by this method 
the surgeon grasps the limb and enters the point of a long 
knife into the tissues at the side nearest himself, and push- 



MODIFIED CIRCULAR OR OVAL METHOD. 483 

ing it across and round the bone or bones brings its point 
out through the skin at a point diametrically opposite its 
point of entrance. He then shapes the flap by cutting 
downward with a rapid sawing motion, and then cuts 
obliquely forward until all the tissues are divided. The 
flap being turned up, he re-enters his knife at the same 
point and passes it on the other side of the bone or bones 
and cuts the second flap in the same manner (Fig. 375). A 
retractor is next applied and the bone is divided with a saw. 

Fig. 375. 




Amputation by antero-posterior flaps. (Bryant.) 

Modified Circular or Oval Method. — In this form of 
amputation two oval antero-posterior or lateral flaps of 
skin are marked out by incisions and dissected up to the 
point at which the muscles and bone are to be divided. 
The muscles are then divided close to the base of the flaps 
by a circular sweep of the knife, and the operation is 
completed by sawing the bones. This form of amputation 
is at present widely employed, and is especially to be recom- 
mended in muscular limbs (Fig. 376). 

Elliptical Method. — This is a form of the oval method 
of amputation which is employed in amputations at the 
knee-joint and elbow-joint, the incision forming an ellipse, 



484 



AMPUTATIONS. 
Fig. 376. 




Modified circular amputation. (Skey.) 

coming below the joint on the front or outside of the limb, 
the resulting flap being folded upon itself. 

Fig. 377. 




Teale's method of amputation. (Bryant.) 

Teale's Method by Rectangular Flaps. — In this 
method of amputation two flaps are made of unequal 
length ; the incisions are so planned that the shorter flap 
contains the main vessel or vessels. The flaps are cut of 



BIER'S OSTEOPLASTIC METHOD. 



485 



equal width and the length of the long flap should be one- 
half of the circumference of the limb at the point where the 
bone is to be divided ; the length of the short flap should be 
one-eighth of the circumference of the limb. The flaps are 
cut from without inward, and embrace all of the tissues 
of the limb down to the bone. After the flaps have been 
dissected up the bone is divided with a saw, and the long 
flap is folded over and sutured to the short flap (Fig. 377). 
The disadvantage of this method of amputation is that 
in muscular limbs it requires the bone to be divided at a 
higher point than would otherwise be necessary. 

Bier's Osteoplastic Method. — To provide a better 
bearing surface for stumps, Bier has recommended an osteo- 
plastic amputation. It may be employed in primary ampu- 
tation or in cases of re-amputation. In amputating the leg 



Fig. 378. 



Fre. 3: 





Bier's osteoplastic amputation of the Bier's osteoplastic amputation of 

leg. the leg, with osteoperiosteal flap in 

position. 

by this method, an oval flap, composed of the skin and 
cellular tissue of one-half of the width of the leg, is dis- 
sected to the point where the bones are to be divided, care 
being taken not to injure the periosteum. A rectangular 
flap of the periosteum, large enough to cover the sawn 
surface of the tibia and fibula, is next marked out by in- 
cisions, the longitudinal incisions extending a little beyond 
the anterior edge of the tibia. The flap is then reflected 



486 AMPUTATIONS. 

about one-half a centimeter from the transverse incision, 
and a thin lamella of bone is next sawed in an upward 
direction with a fine saw, the saw being turned toward the 
periosteum at its upper part to complete the bone flap. 
This flap is turned so as to cover the sawn surface of the 
bones and secured by a few sutures (Figs. 378, 379). The 
amputation is completed by making a circular incision of 
the tissues on the posterior aspect of the leg and sawing 
the bones close to the border of the inverted bone flap. 

Periosteal Flaps. — In any of the methods of amputa- 
tion previously described the periosteum may be dissected 
up in two flaps attached to the muscles, or pushed up as 
a sleeve by means of a director or periosteotome before the 
bone is sawed. This procedure is most easily accomplished 
in young subjects. When these flaps are made and are 
brought together, the periosteum covers the cut surface 
of the bone, to which it soon forms adhesions. 

Instruments Required for Amputations. — The instru- 
ments required for amputations are knives of various 
shapes and sizes, saws, dissecting forceps, bone-forceps, 
artery forceps, tenacula, hemostatic forceps, scissors, peri- 
osteotomies, tourniquets, Esmarch's bandage and strap, 
retractors, ligatures, sutures, and needles. 

Amputating Knives. — The knives required for amputa- 
tions vary according to the method of amputation and the 

Fig. 380. 



Scalpel. 

part to be amputated. In certain amputations a scalpel 
(Fig. 380) or straight bistoury (Fig. 381) may be used, 
while in other cases the employment of amputating knives 
of various sizes will be found more satisfactory. For 
amputations of the thigh a knife with a blade of eight or 
nine inches is generally employed, and for smaller limbs a 
knife with a blade of six or seven inches in length ; double- 
edged catlins are employed in amputations of the leg and 



INSTRUMENTS REQUIRED FOR AMPUTATIONS. 487 

forearm, to divide the interosseous tissues before applying 
the saw. The amputating knives now employed are con- 

Fig. 381. 



Straight bistoury. 

structed with solid metal handles, so that they may be 
rendered thoroughly aseptic by immersion in boiling water 
before being used (Fig. 382). 



Fig. 382. 




Amputating knife and catlin. 



Amputating Saws. — Several kinds of amputating saws 
are in general use ; one with a blade ten inches long by 
two and a half inches wide, with a heavy back to give it 
additional firmness, is a very good variety of saw (Fig. 
383). For amputations about the foot or hand a narrow 



Fig. 383. 




Amputating saw. 



saw with a movable back will be found very convenient 
(Fig. 384). A bow saw with a metallic handle and a re- 
versible blade is a very useful variety of saw, as it can be 
used either in amputations or in excisions, and, being con- 



488 



AMPUTATIONS. 
Fig. 384. 




Small amputating saw. 

structed entirely of metal, it can be easily rendered aseptic 
(Fig. 385). 

Fig. 385. 




Amputating saw with reversible blade. 

Bone-forceps, or Cutting Pliers. — These instruments are 
used in smoothing off any rough edges of bone left after 
the use of the saw, or for the division of the small bones 
in amputations of the fingers and toes. The forceps should 
be from ten to twelve inches in length, with blades from 
one to one and a half inches in length (Fig. 386). 

Fig. 386. 




Bone-forceps, or cutting pliers. 

Periosteotome. — The periosteotome, or raspatory, is em- 
ployed for dissecting up a flap of periosteum, which, after 
sawing the bone, is drawn down over the sawed end of the 
bone (Fig. 387).' 

Artery Forceps and Tenacula. — These instruments are 
used for taking up the vessels, and one of the best forms 



INSTRUMENTS REQUIRED FOR AMPUTATIONS. 489 

Fig. 387. 




Periosteotome. 

of artery forceps is that known as the double-spring artery 
forceps (Fig. 216)« Tenacula are also employed for the 
same purpose (Fig. 217). Haemostatic forceps will also be 
found most useful in cases of amputation, for the rapid 
control of hemorrhage from small vessels after the tourni- 
quet has been removed, the vessels being secured by 
torsion or by ligatures before the haemostatic forceps are 
removed. 

Retractors. — These consist of pieces of sterilized muslin 
six or eight inches in width, one end of which is split 

Fig. 388. 




Retractor applied. (Esmarch.) 

into two or three tails ; the former variety of retractor is 
employed where one bone is divided, as in amputations 



490 AMPUTATIONS. 

of the arm and thigh (Fig. 388). and the latter in cases 
where two bones are divided, as in amputations of the 
forearm and leg. 

Ligatures. — The best material to employ for the ligature 
of vessels is plain or chromicized catgut or sterilized silk, 
the preparation of which has been described (page 13*.'»). 

Sutures. — The materials employed for sutures in cases 
of amputation may be silkworm-gut, catgut, silk, or silver 
wire ; deep or buried sutures of catgut, bringing together 
the edges of the periosteal flaps, muscles, and fascia, are 
often employed with advantage in amputations (Fig. 389), 
the skin flaps being brought together with interrupted or 

Fig. 389. Fig. 390. 



Deep or buried sutures of muscles. Sutures of the skin. 

(ESMAKCH.) (ESMARCH.) 

continuous sutures of silk, catgut, silkworm-gut, or silver 
wire (Fig. 390). 

Tourniquets. — For the control of hemorrhage during 
amputation the Esmarch apparatus (Fig. 215) or Petit's 
tourniquet (Fig. 209) is employed ; or the employment of 
both at the same time will often be found most satisfactory. 
The Esmarch bandage and tube being applied, after re- 
moval of the bandage, the tourniquet of Petit is loosely 
applied at a higher point, and after the main vessels have 
been secured the elastic strap is removed, and the tourni- 
quet is screwed down and controls the bleeding until the 
smaller vessels have been secured by ligatures. Wyeth's 



DETAILS OF AN AMPUTATION. 491 

pins may be used in conjunction with the elastic strap in 
amputations at the hip-joint and shoulder-joint. 

Details of an Amputation. — The following are the 
steps of an amputation of the lower part of the thigh : 

The skin is first thoroughly cleansed by scrubbing it with 
turpentine, soap and water, and alcohol. It is then washed 
with a solution of bichloride of mercury, 1 : 2000. Provi- 
sion is next made to prevent the loss of blood during the 
operation by the application of Esmarch's bandage and 
tube ; the bandage being removed a tourniquet is placed 
over the femoral artery in Scarpa's triangle and loosely 
secured. The limb is again washed with bichloride solu- 
tion. The instruments having been previously thoroughly 
sterilized, a rubber cloth covered with sterilized towels 
wrung out in a bichloride solution is placed under the limb. 
The variety of amputation having been decided upon, the 
flaps are cut and the muscles are divided down to the bone ; 
the periosteum being dissected up, a two-tailed retractor 
is applied, and the tissues are held back by an assistant 
while the surgeon divides the bone with the saw. When 
the bone has been divided the retractor is removed. Irri- 
gation of the surface of the wound is not necessary if the 
operation has been an aseptic one. Sterilized gauze pads 
may be employed to wipe away the blood. The femoral 
artery and vein are next found and secured with ligatures, 
and any muscular branches which can be found are also 
secured. The elastic strap is removed after screAving down 
the tourniquet, and by gradually letting up the pressure 
on the smaller vessels which bleed, they are picked up 
with artery forceps or hemostatic forceps and secured. 
After all bleeding has been controlled the tourniquet is 
removed. If there is much oozing from the smaller ves- 
sels, irrigation with hot saline solution or sterilized w T ater 
may be employed ; the fluid should be as hot as the hands 
of the operator can comfortably stand, which will act 
promptly in controlling this variety of bleeding. The 
periosteal flaps, if they have been made, are brought 
together by two or three catgut sutures, and a long drain- 
age-tube is next introduced, or two short tubes are intro- 



492 



AMPUTATIONS. 



duced at either extremity of the wound and secured by 
sutures or safety-pins. Drainage may be omitted, but I 
consider it wise to employ it in major amputations. The 
muscles and tendons should next be brought together over 
the face of the stump by a few deep or buried sutures of 
catgut, thereby making a good cushion and tending to 
lessen the subsequent muscular atrophy, and the skin Haps 
should then be brought into apposition by a number of 
interrupted sutures (Fig. 391). The surface of the stump 
is next washed with salt solution or sterilized water, and a 

Fig. 391. 




Stump showing application of sutures and drainage-tubes. (Smith.) 



number of layers of dry sterilized gauze are applied over 
its surface and over the gauze dressing a number of layers 
of sterilized cotton are placed, and the whole dressing is 
held in place by a recurrent bandage of the stump. 

If the antiseptic method is employed, the surface of the 
wound is irrigated at intervals during the operation with a 
1 : 2000 bichloride solution, and the stump is dressed with 
moist or drv bichloride gauze and bichloride cotton. 

Re-dressing of Amputations. — The first dressing of 
an amputation, if strict antiseptic precautions have been 



&E-DBESSIXG OF AMPUTATIONS. 493 

observed at the time of operation, need not, as a rule, be 
made for a week or ten days, except in cases where the 
oozing is so profuse as to soak the dressings, or where con- 
secutive hemorrhage has occurred, or the patient's condi- 
tion shows that the wound is not running an aseptic course. 
The re-dressing of a stump can be accomplished without 
pain to the patient if the surgeon and his assistants are 
careful in their manipulations. 

The dressings to be applied, the solutions for irrigation, 
and the instruments required should be prepared and at 
hand before the stump is exposed. The surgeon and his 
assistants should wash their hands carefully, and then soak 
them in a 1:2000 bichloride solution. The bandage 
retaining the dressings to the stump should be divided 
with bandage scissors without lifting the stump from the 
pillow upon which it rests. After the bandage has been 
divided and turned aside, the gauze dressing is next 
unfolded and turned down ; an assistant now slips his 
hands under the stump and gently raises it from the dress- 
ings, and at the same time a rubber cloth covered with 
sterilized towels or towels which have been wrung out in a 
1 : 2000 bichloride solution is slipped under the stump and 
the soiled dressings are removed. If the dressings are 
adherent at the line of incision, irrigation with saline solu- 
tion or distilled water may be employed to soften them and 
facilitate their removal. 

If the wound is aseptic and there seems to be no further 
indication for the use of the drainage-tubes, they may be 
removed. The sutures are next examined, and if the 
wound is firmly healed alternate sutures may be removed ; 
if catgut or silkworm-gut sutures have been used, they 
need not be disturbed at this dressing, and their removal 
may be postponed until a subsequent dressing. 

The wound should next be covered with a sterilized 
gauze dressing consisting of a number of layers, and over 
this several layers of sterilized cotton, and the dressings 
should be held in place by a recurrent bandage of the 
stump. If the antiseptic method has been employed the 
stump may be irrigated with a 1 : 2000 bichloride solution 



494 



AMPUTATIONS. 



and a dressing of bichloride gauze and cotton used to 
cover the stump. The assistant should hold the stump 
firmly, to prevent muscular spasm, and after the dressings 
have been secured it should be placed upon a clean pil- 
low prepared for its reception. The same procedures are 
adopted at subsequent dressings ; and if the wound has 
run an aseptic course, two or three dressings, at most, 
will be required. 

AMPUTATIONS OF THE HAND. 

Amputations of the Fingers. — The fingers may be 
amputated in the continuity of the phalanges or in their 
contiguity, and, as a rule, as it is important to save as much 



Fro. 392. 





Amputation of a finger by the long palmar flap. (After Esmaech.) 

as possible of the finger, the former method is generally to 
be employed instead of disarticulation at a higher point. 
The incision should be so planned that the cicatrix does 
not occupy the palmar surface ; the larger flap should, 
therefore, be taken from the palmar aspect of the finger. 
In amputating the phalanges of the fingers in their con- 
tinuity, the circular method (Fig. 396, B) or a short 



AMPUTATION OF THE FINGER. 



495 



dorsal flap and a long palmar flap may be employed. In 
disarticulating a phalanx it is best to enter the joint with a 
narrow knife from the dorsal side, and after having 
carried it through the joint, to cut a long palmar flap, 
keeping close to the bone (Fig. 392). In locating the 
position of the phalangeal joints, it is well to remember that 
the prominence of the knuckle when the finger is flexed is 
formed entirely of the head of the proximal and not of the 



Fig. 393. 



Fig 





Phalanges flexed. 



Guides to articulations of the fingers, a, head 
of metacarpal bone ; b, metacarpophalangeal 
articulation ; c, relation of palmar fold to articu- 
late >n ; d, e, interphalangeal articulation ; /, ar- 
ticulation of distal phalanx. (Smith.) 



base of the distal phalanx (Fig. 393), and also that the folds 
on the palmar surface of the finger do not correspond 
exactly to the joints (Fig. 394). 

Amputation of the Finger through the Metacarpo- 
phalangeal Articulation. — In this variety of amputation 
an incision is made from a point on the dorsal surface of 
the metacarpal bone a quarter of an inch above the articu- 
lation, which is carried through the interdigital web and 
back upon the palmar surface to a point a quarter of an inch 
above the flexor fold (Fig. 396, O). A similar incision be- 



496 



AMPUTATIONS. 



ginning and ending at the same points is made upon the 
opposite side of the finger. The flaps are dissected back, 
and the lateral ligaments, tendons, and remainder of the 
capsule are divided (Fig. 395). The finger may also be 
amputated at the metacarpophalangeal joint by making 
an incision on one side and dissecting the flap back to the 
joint, then dividing the lateral ligament, opening the joint 

Fig. 395. 




Racket-shaped incision for amputation of the finger at the metacarpo- 
phalangeal joint. (After Rotter.) 



and carrying the knife across this, dividing the tendons 
and lateral ligament on the other side and cutting a flap 
from within outward. 

Removal of the head of the metacarpal bone if desired 
may be accomplished by the use of cutting pliers (Fig. 
397); but, as a rule, this procedure is not to be recom- 
mended, for, although the deformity is lessened, the 
strength of the hand is diminished. 



AMPUTATIONS OF THE METACARPAL BOXES. 497 

In amputating the little and index fingers a full lateral 
flap may be cut on the free side, and an incision is next 
carried across the palmar surface to the angle of the web, 
and thence back to the joint, which is opened and the dis- 
articulation effected (Fig. 396, E). 

Fig. 396. 




A. Disarticulation of distal phalanx: palmar flap. B. Amputation in con- 
tinuity by a circular flap. C. Metacarpophalangeal disarticulation. D. Ampu- 
tation of metacarpal bone in continuity. E. Disarticulation of little finger. 
F. Disarticulation of fifth metacarpal "bone. G. Amputation at the wrist, 
circular. H. Amputation at the wrist, lateral. (Stimson.) 



Amputations of the Metacarpal Bones. — In ampu- 
tating the metacarpal bones it is advisable to leave the 
carpal ends of the bones to avoid opening the wrist-joint, 
except in the case of the first and fifth metacarpal bones, 
which do not communicate with the others and with the 
synovial sacs. 

The incisions for the removal of the metacarpal bones 

32 



498 



AMPUTATIONS. 



are the same as for the removal of a finger at the meta- 
carpophalangeal joint, the incision being prolonged back- 
ward as far as necessary over the dorsal surface of the 
bone (Fig. 396, _D.) After the metacarpal bone has been 
bared for a sufficient distance, it is cut through with bone- 
pliers or disarticulated, and the distal end is raised from 
its bed and carefully separated from the soft parts, care 
being taken to avoid injury of the structures of the palm 
of the hand. 

Fig. 397. 




Removal of the head of a metacarpal bone. (Skey.) 

In amputating the fifth metacarpal bone, the incision 
should be made along the inner border of the hand and 
carried down to the bone between the skin and the ab- 
ductor minimi digiti muscle (Fig. 398). The lower end 
of the incision passes over the knuckle to the web of the 
finger, and backward under the palmar surface to join the 
first incision. 

Amputation of the entire thumb with its metacarpal 
bone is effected by making an oval flap from the palmar 



AMPUTATIONS AT THE WRIST. 499 

surface ; in the case of the left thumb, the joint may be 
opened by an oblique incision on the dorsal surface of the 
hand, beginning a little in front of the joint and being 
carried down to the web between the thumb and fore- 
finger; the palmar flap is then made by thrusting the knife 
upward to its point of entrance and cutting downward 
and outward. In amputating the right thumb with its 
metacarpal bone, it is better to make the palmar flap first 
by transfixion, the dorsal flap being made subsequently. 

Fig. 398. 




Incision for removal of the fifth metacarpal bone. (Smith.) 

Amputation of the hand at the carpo-metaearpal joint is 
occasionally performed, or between the rows of carpal 
bones ; but is not, as a rule, to be recommended, as the 
carpal bones are apt subsequently to become diseased and 
require removal ; it is, therefore, better to amputate at the 
radio-carpal joint. 

AMPUTATIONS AT THE WRIST. 

Circular Method. — The skin of the forearm near the 
wrist being retracted by an assistant, a circular incision of 
the skin and cellular tissue is made half an inch below the 
point of the styloid process of the radius (Fig. 396, G). 
The skin and cellular tissue are next dissected back as far 
as the joint, which is opened and the disarticulation com- 
pleted. 

Antero-posterior Flap Method. — This method is also 
employed in amputations at the wrist-joint ; an incision 
curved downward is made on the back of the hand from 
one styloid process to the other ; the hand being flexed, 
the tendons are divided and the joint opened, and the 



500 AMPUTATIONS. 

palmar flap, which should extend as far as the base of the 
metacarpal bones, is cut from within outward (Fig. 399). 
Amputation at the wrist is sometimes performed by cut- 
ting a single flap from the palm, the joint being opened 
by a transverse incision on the back of the hand from one 
styloid process to the other. 

Fig. 399. 




Amputation at the wrist. (Erichsen.) 

Lateral Flap Method.— This method (Fig. 396, H) is 
also sometimes employed in amputation at the wrist, and 
may be employed with advantage in cases of laceration of 
the hand, in which the injury to the tissues is so great 
as to prevent the formation of the flaps used in the other 
methods of amputation. 



AMPUTATIONS OF THE FOREARM. 

The forearm may be amputated by the circular or flap 
method, or by making rectangular flaps (Teale's method). 

Circular Method. — At the lower portion of the forearm 
the circular method of amputation is to be preferred. A 
circular incision of the skin and cellular tissue is made and 
a cuff is dissected up, the muscles and interosseous mem- 






AMPUTATIONS AT THE ELBOW. 501 

brane being cut through ; a three-tailed retractor is next 
applied and the bones are divided with a saw. 

Modified Circular Method— Amputation of the fore- 
arm by the oval or mixed method, which consists in first 
dissecting up two antero-posterior oval flaps of skin and 
cellular tissue and then dividing the muscles by a circular 
incision, is also a satisfactory operation (Fig. 400). 

Fig. 400. 




Amputation of the forearm by the modified circular method. (Bryant.) 

In amputation at the upper portion of the forearm, 
antero-postey*ior or lateral flaps, cut from without inward 
or by transfixion, or rectangular flaps, may be made with 
advantage. 

AMPUTATIONS AT THE ELBOW. 

The methods of amputation employed at the elbow are 
the anterior flap, lateral flap, circular, and elliptical. 

Anterior Flap Method. — A flap three inches in length, 
with its base parallel to and half an inch below the 
condyles of the humerus, is cut either by transfixion or 
from without inward. The joint is next opened and the 
lateral ligaments divided. The olecranon is then ex- 
posed, the attachment of the triceps muscle separated, 
and a posterior flap cut from without inward, or from 
within outward, a little below the line of the Condyles 
(Fig. 401, A). 

Lateral Flap Method. — In amputation at the elbow- 
joint lateral flaps may be employed, cut either from with- 
out inward or by transfixion (Fig. 401, B). A flap three 
inches in length is made on the outer side of the forearm, 
starting from a point a finger's breadth below the bend 



502 



AMPUTATIONS. 



Fig. 402. 



Fig. 401. 





Circular amputation at the elbow. (Smith.) 



Amputation at the elbow-joint. A. An- 
terior flap method. B. External flap 
method. C. Circular method. (Stimson.) 




Incision for elliptical amputation 
at the elbow. (After Treves.) 



of the elbow, by transfixion or by cutting from without 
inward ; a shorter internal flap is next cut in the same 
manner, and the joint is opened and the disarticulation 
effected. 

Circular Method. — An incision dividing the skin and 
cellular tissue is made around the limb three inches below 
the line of the condyles of the humerus (Fig. 401, C), 
the skin is dissected up and a circular incision made 



AMPUTATIONS OF THE ARM. 



503 



through the muscles, the joint is opened and the disar- 
ticulation effected (Fig. 402). 

Elliptical Method. — In this method of amputating at 
the elbow an incision is carried from the olecranon process 
downward and forward to a point a little above the middle 
of the forearm ; it is then continued across the anterior 
aspect of the limb, and is carried back to the olecranon 
process (Fig. 403). The incision includes only the skin 
and the cellular tissue. The flap having been dissected 
up for a short distance, the soft parts close to the joint 
are transfixed ; the muscles are cut obliquely, so that an 
anterior flap is formed. This flap is held up, the bones 
are disarticulated, the attachment of the triceps tendon to 
the olecranon is divided, and any tissues which have 
escaped division along the posterior aspect of the limb 
are severed. After the vessels have been secured, the flap 
is turned over and sutured, and a curved cicatrix on the 
posterior aspect of the limb results. 



Fig. 404. 



AMPUTATIONS OF THE ARM. 

The arm may be removed at any point below the attach- 
ment of the muscles at the axilla, by either the circular, 
flap, oval, or modified circular 
method. 

Circular Method. — This am- 
putation is usually employed in 
removing the arm in its lower 
third. A circular incision of 
the skin and subcutaneous tis- 
sue is first made, and when the 
cuff has been dissected up, a cir- 
cular division of the muscles is 
made ; after applying the re- 
tractor the bone is sawed through 
(Fig. 404). 

Transfixion Method.— From 
the central position of the bone 
in the arm the flap method in 
amputating the arm is preferred by many operators. The 




Circular amputation of the arm. 
(Smith.) 



504 AMPUTATIONS. 

arm being grasped by the hand, the point of a medium- 
sized amputating-knife is thrust through the arm so as to 
pass over the humerus and make its exit at a correspond- 
ing point in the skin on the opposite side ; a flap of suffi- 
cient length is cut from within outward. The knife is 
next passed behind the bone and a posterior flap is cut in 
the same manner (Fig. 405) ; the bone is next cleared of 
muscular tissue, the flaps are retracted, and it is divided 
with a saw. 

Lateral flaps may be made in this amputation instead 
of the antero-posterior flaps, and they may be cut from 
within outward in the same manner. 

Fig. 405. 



Amputation of the arm by transfixion. (Bryant.) 

Modified Circular Method. — This method of amputat- 
ing the arm is also employed with advantage. Two oval 
flaps of skin and cellular tissue are dissected up, and the 
muscles divided by a circular sweep of the knife. 

In high amputations of the arm there is sometimes not 
sufficient room to apply Esm arch's strap or a tourniquet 
to the arm itself to control the hemorrhage during the 
operation ; in such cases the strap may be passed from the 
axilla around the outer end of the clavicle, as is done to 
control the bleeding during amputation at the shoulder- 
joint (Fig. 406), or Wyeth's pins may be employed. 






AMPUTATIONS AT THE SHOULDER- JOIST. 505 
Fig. 406. 




Esmarch's strap applied in high amputation of the arm. (Smith.) 
Fig. 407. 




Amputation at the shoulder-joint. A. Oval, or Larrey's method. B. Double- 
flap, or Dupuytren's method. ^Stimson.) 

AMPUTATIONS AT THE SHOULDER-JOINT. 

Several methods of operation are employed in ampu- 
tating at the shoulder-joint, such as Larrey's method, 
Lisfrane's and Dupuytren's methods, and Spence's methoo 



506 AMPUTATIONS. 

(Fig. 407). The control of the bleeding from the axillary 
artery during the operation is a matter of the first impor- 
tance ; it may be arrested by pressure made upon the 
subclavian artery, as it crosses the first rib, with the 
thumb, or the padded handle of a large key, or by the 
fingers of an assistant grasping the axillary flap and com- 
pressing the vessel after the head of the bone has been 
disarticulated, or by the use of an elastic strap applied 
around the axilla and shoulder (Fig. 406). 

Wyeth's pins may also be employed with an elastic tube 
or strap to control bleeding during amputation at the 

Fig. 408. 




s. 



Method of applying Wyeth's pins. 

shoulder-joint. The anterior pin is passed through the 
anterior fold of the axilla, and is brought out in front of 
the acromion, the posterior pin is passed through the pos- 
terior fold of the axilla and is brought out behind the acro- 
mion, the rubber strap or tube is then wrapped around the 
shoulder behind the pins and controls the hemorrhage dur- 
ing the operation (Fig. 408). 

Larrey's Method. — In this method of amputation the 
point of the knife is entered just below the acromion 
process, and a deep incision three inches in length is made 
down to the head of the bone along the axis of the arm ; 
from the middle of this incision two others are made 
obliquely downward to the points where the anterior and 
posterior folds of the axilla end in the tissues of the arm ; 



DUPUYTREN'S METHOD. 



507 



the latter incisions should be only sufficiently deep to divide 
the skin and superficial fascia (Fig. 407, A). The flaps 
are then dissected up until the head of the bone is well 
exposed, and, after opening the capsule and dividing the 




Amputation at the shoulder-joint by Larrey's method. 

muscles inserted into the neck and tuberosities of the 
humerus, which division may be facilitated by rotating 
the head of the bone outward and inward, the disarticu- 
lation is effected by adducting the elbow ; the knife is 
next passed downward behind the bone and made to cut 
outward in the line of the cutaneous incisions, an assistant 
controlling the artery before it is divided by grasping 
the axillary tissues behind the knife with his fingers if 
Wyeth's pins have not been employed. 

Dupuytren's Method. — In this method of amputation 
at the shoulder-joint the flaps may be cut either by trans- 
fixion or from without inward ; the large flap embraces 



508 



AMPUTATIONS. 



the greater part of the deltoid muscle (Fig. 407, E), and 
the smaller or short flap is cut from the inside of the arm 
after the head of the bone has been disarticulated. "When 
cut by transfixion, the point of the knife should be entered 
an inch in front of the acromion process and pushed across 
the outer aspect of the head of the humerus, and brought 
out at the posterior fold of the axilla ; the knife is made 
to cut downward until a large deltoid flap is formed. 
This flap is turned up and the head of the bone is dis- 
articulated ; the knife being placed behind it, a short flap 

Fig. 410. 




Amputation at the shoulder-joint. Dupuytren's method. (Bryant.} 

is formed, keeping close to the bone, so that the vessels 
are divided with the last cut of the knife (Fig. 410). An 
assistant should control the vessel by grasping the axillary 
tissues with his fingers behind the knife. 

Lisfranc's Method. — In this method of amputation at 
the shoulder-joint the point of the knife is entered at the 
outer side of the coracoid process, and is carried across the 
outer aspect of the head of the humerus and brought out 
a little below the posterior border of the acromion process, 
and a long flap is cut downward. This flap is turned up 
and the attachments of the head of the bone are divided 
and it is disarticulated. The knife is again entered behind 



AMPUTATION ABOVE THE SHOULDER-JOINT. 509 



Fig. 411. 



the bone, and a long posterior flap cut from within out- 
ward. 

Spence's Method. — In this method of amputation at 
the shoulder-joint an incision is made down to the head of 
the humerus immediately in front of 
the coracoid process, and is continued 
downward through the clavicular fibres 
of the deltoid and the pectoralis major 
muscles until the attachment of the lat- 
ter to the humerus is reached (Fig. 411). 
The incision is now carried backward 
to the posterior fold of the axilla. A 
second incision, including only the skin 
and cellular tissue, is next made from 
the anterior portion of the first incision 
across the inside of the arm to meet the 
incision on the outer part. The outer 
flap thus formed is turned up and the 
head of the bone is disarticulated. The 
operation is completed by dividing the 
remaining tissues on the axillary aspect. 

Amputation above the Shoulder- 
joint. — This form of amputation con- me thod. (Stimson.) 
sists in removal of the arm with a part 
or the whole of the scapula, and a portion or whole of the 
clavicle. 

As this form of amputation is required in cases in which 
the laceration of the parts has extended beyond the shoul- 
der-joint, or in cases of growths involving the tissues be- 
yond the joint, no definite rule can be laid down for the in- 
cisions ; the only rule being as far as possible to make them 
in such a manner that the smallest amount of skin is sacri- 
ficed, so that a sufficient covering for the wound may be 
obtained. Treves recommends the following method : The 
patient should be placed on his back close to the edge of 
the operating-table. An incision should be made over the 
clavicle, extending from the inner extremity outward to a 
point a little beyond the acromio-clavicular articulation, 
which should be carried down to the bone ; the clavicle 




Amputation at the 
shoulder-joint. Spence's 



510 AMPUTATIONS. 

being exposed, it should be divided in its middle third or 
disarticulated from the sternum, and, its outer portion 
being lifted up, it is disarticulated at its acromial ex- 
tremity. The subclavian vessels are thus exposed, and 
should be tied by two ligatures, about an inch apart, and 
the vessels finally divided between the ligatures. The 
axillary plexus of nerves should next be divided. The 
second incision is made at the centre of the first incis- 
ion, and the knife is carried directly across the anterior 
part of the axilla and inner border of the arm to the 
inferior angle of the scapula ; from the outer extremity of 
the first incision over the clavicle a third incision should 
be made posteriorly, across the dorsum of the scapula to 
its inferior angle, joining the termination of the second 
incision (Fig. 412). Upon turning back the posterior flap 

Fig. 412. 




Amputation of arm, scapula, and clavicle, the dotted line representing the 
posterior incision. (Tkeves.) 

thus formed and severing the connections of the scapula 
with the trunk and the muscular attachments which remain 
anteriorly, the upper extremity will be entirely freed from 
the trunk. The wound, when closed, forms an oblique line 
running from above downward, outward, and backward. 



AMPUTATIONS OF THE FOOT. 



511 



AMPUTATIONS OF THE FOOT. 

Amputations of the Toes. — The phalanges of the toes 
may be removed in the same manner as those of the fin- 
gers. It is better to amputate at the metatarso-phalangeal 



Fig. 413. 



Fig. 414 




Amputation of the toes by the 
racket-shaped incision and flap 
method. (After Hotter.) 




Incisions for amputation of toes and 
metatarsal bones. (Stimson.) 



articulations than to attempt to remove them at the joints 
in front of this articulation, except in the case of the great 
toe, as the preservation of a portion of a toe is rather a 
discomfort than an advantage, except in the instance men- 
tioned. All incisions should be made so that the resulting 
cicatrix does not occupy the plantar surface, and it is well 



512 



AMPUTATIONS. 



to remember that the web of the toes is considerably below 
the position of the metatarso-phalangeal joint. 

The toes are usually removed by an incision on the 
dorsal surface a little above the joint, which is carried 
down to the bone for about an inch and then diverges into 
the web, and is carried under the toe and back on the 
other side to the point of divergence (Figs. 413, 414). 

Amputation of Two Adjoining Toes. — The dorsal incision 
should be made in the inter-metatarsal space just above 
the level of the joint (Fig. 414, B) and carried down to 
the beginning of the web ; then over the toes to the be- 
ginning of the adjoining web ; then under the plantar 
surface of both toes in the line of the digi to-plantar fold, 
through the web, and back to the point of divergence. 

Fig. 415. 




Amputation of the great toe and first metatarsal bone. (Smith.) 

Amputation of the Great Toe. — This may be accomplished 
by means of the racket-shaped incision employed in am- 
putation of the other toes (Fig. 413), or by means of a 
lateral flap. In the latter case the knife is made to enter 
the joint by cutting through the commissure, and the 
operation is completed by carrying the knife through the 
joint and along the outer side of the bone, forming a flap 
of the required size. In this amputation a short dorsal 






AMPUTATIONS OF THE FOOT. 513 

flap and a long plantar flap may be employed, or a large 
internal flap may be used. 

Amputation of the Great Toe with its Metatarsal Bone. — 
The incision begins upon the dorsal surface of the meta- 
tarsal bone, a little below the point at which the bone is to 
be divided, and is carried down below the metatarso- 
phalangeal joint, then diverges and passes under the toe, 
and comes back again to the point of divergence (Fig. 
414, C). The bone is exposed and cut through with cut- 
ting forceps, and is then lifted up and dissected loose from 
the tissues (Fig. 415). 

Amputation of All the Toes. — To amputate all the toes, 
make a dorsal incision from the head of the fifth to the 
head of the first metatarsal bone ; the incision should be 
a curved one passing just in front of the joints (Fig. 416). 
Dissect up the flap and open the joints, dividing the lateral 
ligaments, and pass the knife behind 
the phalanges and cut a flap from the 
plantar surface. 

Amputations of the Metatarsal 
Bones. — It is better in these amputa- 
tions to leave the tarsal head of the 
metatarsal bone in place and divide the 
bone, or, in other words, to do an am- 
putation in continuity to prevent open- 
ing up the tarsal articulations. 

Amputation of the Little Toe and the 
Fifth Metatarsal Bone. — The incision 
for the removal of the little toe and the I gSttltoS a ^SS3 
fifth metatarsal bone is made over the 
bone a little below the metatarso-tarsal articulation, and is 
carried down and curved around the toe (Fig. 414, D), 
and after the bone is exposed by dissecting back the 
flaps it is divided, or the joint is opened and it is 
dissected out. 

Amputation through all the Metatarsal Bones. — In per- 
forming this amputation an incision is made across the 
dorsum of the foot, and a short dorsal flap is dissected up ; 
the metatarsal bones are next divided with a saw and a 




514 



AMPUTATIONS. 



long plantar flap is cut from within outward by entering 
the knife behind the ends of the bones. 

Tarso -metatarsal Amputations. — In all amputations 
of the foot involving the tarsus the surgeon should be 
thoroughly familiar with the anatomy of the foot and the 
surgical landmarks of the different articulations. I shall 



Fig. 417. 



Fig. 418. 





Surgical guides to the foot as expressed 
by anatomy. (Bryant.) 



Incisions for — A. Lisfranc's am- 
putation. B. Chopart's amputa- 
tion/ (Stimson.) 



refer to those laid down by Mr. Bryant, which are as 
follows : 

" On the inner side of the foot, not far from the inner 
malleolus, the tubercle of the scaphoid (Fig. 417, A) is to 
be felt as a marked prominence ; about one-half an inch 



TARSO-METATARSO AMPUTATIONS. 515 

in front of this will be found the articulation with the 
cuneiform bone (B), and one inch in front of this the joint 
which the surgeon will have to open in Lisfranc's or Hev's 
operation (C); just above the tubercle of the scaphoid will 
be found the articulation with the astragalus, the line of 
Chopart's amputation (D). On the outer side of the foot, 
one inch below the external malleolus, a sharply denned 
projection will always be felt, which is the peroneal 
tubercle (E ) ; one-half an inch in front of this will be 

Fig. 419. 




Amputation at the tarsometatarsal joint. (Lisfranc's.) 

found the joint which separates the os calcis from the 
cuboid (F), this joint forming the outer circle to Chopart's 
amputation. Half an inch in front again, or one inch 
from the tubercle, the prominence of the fifth metatarsal 
bone is always to be felt (H), the line above this promi- 
nence indicating the articulation with the cuboid bone, 
which forms the outer boundary of the incision for Hey's 
or Lisfranc's operation." 



516 



AMPUTATIONS. 



Tarso -metatarsal Amputation (Lisfranc's). — The in- 
cision for this amputation is a curved one carried across 
the dorsum of the foot from the base of the fifth to the 
base of the first metatarsal bone (Fig. 418, A). The in- 
cision should involve the skin only, its centre lying half 
an inch or more below the centre of the line of the articu- 
lations, and it should begin and end at the sides of the 
foot at their junction with the sole. A plantar flap should 
be marked out by a curved incision crossing the sole of 
the foot near the origin of the toes, starting and ending at 
the same points as the dorsal incision. 

The dorsal flap is next dissected back to the line of the 
articulations ; the tendons, muscular fibres, and fascia 
being divided, the joints between the tarsal and metatarsal 
bones are opened with a stout, narrow-bladed knife (Fig. 



Fig. 420. 




Lines of incision for — A. Chopart's amputation. B. Syme's amputation. 
D. Section of bone in Syme's amputation. C. Subastragaloid amputation. 
(Stimson. ) 






419). Difficulty is sometimes experienced in opening the 
joint between the head of the second metatarsal bone and 
the second cuneiform bone, which occupies a position higher 
on the foot than the other articulations. The disarticu- 
lation may also be facilitated by forcibly depressing the 



MEDIO-TA ESAL AMP UTA TION. 



517 



anterior portion of the foot. After all the joints have 
been opened, the knife is passed behind the ends of the 
metatarsal bones, and a plantar flap is cut from within 
outward, following the line of the incision previously 
marked out. The plantar flap may be cut from without 
inward if preferred. 

Tarso-metatarsal Amputation (Hey's). — The line of 
incision and the steps of this operation are similar to those 
in Lisfranc's amputation, with the exception that Hey 
sawed off the projecting portion of the internal cuneiform 
bone after disarticulating the metatarsal bones. This 
modification, although it improves the appearance of the 
stump, possesses no advantages over the latter procedure. 

Medio-tarsal Amputation (Chopart's). — In this ampu- 
tation the disarticulation is through the joints formed by 



Fig. 421. 




Chopart's amputation. (Bryant.) 

the astragalus and calcaneum behind and the scaphoid and 
cuboid in front. An incision is made from the tubercle 
of the scaphoid across the dorsum of the foot an inch in 
front of the head of the astragalus to the lower and outer 
border of the cuboid (Fig. 418, B). The plantar flap is 
next marked out by an incision beginning and ending at 
the same points as the first incision and crossing the sole 
of the foot four or five finger-breadths nearer the toes 



518 



AMPUTATIONS. 



(Fig. 420, A). The dorsal flap is next dissected up, and 
after the tendons and fascia have been divided the joint 
is opened and a plantar flap is cut from within outward, 
following the line of the previously marked-out plantar 
incision (Fig. 421). 

Subastragaloid Amputation. — In this amputation all 
the bones of the foot are removed except the astragalus. 
An incision is made, beginning an inch below the tip of 
the external malleolus, which is carried forward to the 
base of the fifth metatarsal bone ; it is then carried over 
the dorsum of the foot to the calcaneo-cuboid articulation 
(Fig. 420, O). The joints between the scaphoid and 

Fig. 422. 




Syme's amputation at the ankle-joint. (Skey.) 

astragalus and between the astragalus and os calcis are 
opened, and the latter bone is carefully dissected out; 
the ligaments are divided and the astragalus only is 
allowed to remain in place. 



AMPUTATIONS AT THE ANKLE-JOINT. 

Syme's Amputation at the Ankle-joint. — In this 
amputation, the foot being at a right angle to the leg, an 



AMPUTATIONS AT THE ANKLE-JOINT. 



519 



incision is made from the centre of one malleolus directly 
across the sole of the foot to the centre of the opposite 
malleolus (Fig. 420, B). The tissues of the heel are 
next carefully dissected from the bone by keeping the 
knife close to the osseous surface until the tuberosity of 
the os calcis is fairly turned (Fig. 422). The two extremi- 
ties of the first incision are then joined by a transverse 
one across the instep, and, the joint being opened, the 



Fig, 423. 




Pirogoff' s amputation. A. Cutaneous incision. B. Line of section of bones. 

(Stimson.) 

lateral ligaments are divided to complete the disarticula- 
tion. The knife is next used to clear the malleoli, and 
they are next removed by the saw in the line indicated 
(Fig. 420, D). 

Pirogoff 's Amputation at the Ankle-joint.— In this 
amputation the posterior portion of the os calcis is re- 
tained. The incision is carried from the tip of the inner 
malleolus, over the instep, half an inch in front of the 
anterior edge of the tibia, to a point half an inch in front 
of the tip of the outer malleolus ; a second incision, cross- 
ing the sole of the foot and carried down to the bone, is 
next made (Fig. 423, .4). The plantar flap is dissected 
back for a quarter of an inch, the joint is opened by 



520 



AMPUTATIONS. 



dividing the lateral ligaments, the astragalus is disarticu- 
lated, and the malleoli are exposed. A narrow saw is next 
applied to the upper and posterior part of the calcaneum 
behind the astragalus, and the former is divided obliquely 
downward in the line of the plantar incision (Fig. 424). 
The malleoli and a thin slice of the tibia are next removed 
with the saw, as in Syme's amputation (Fig. 423, B). 
Some surgeons do not remove the malleoli, but press the 
sawed surface of the os calcis between them when it is 
possible to do so. The position of the os calcis in relation 
to the tibia after union has occurred is shown in Fig. 425. 



Fig. 424. 




Application of saw to os calcis in Pirogoff' s amputation. (Erichsen.) 

Roux's Amputation at the Ankle-joint. — In this 
method of amputation an incision is made at the outer 
edge of the tendo-Achillis, a little above its insertion, 
which is carried forward under the outer malleolus, and 
across the instep half an inch in front of the anterior 
edge of the tibia, and back to a point just in front of 
the inner malleolus ; the incision is carried from this 
point downward and partly across the sole of the foot, 
and then back to the point of origin of the original in- 



AMPUTATIONS OF THE LEG. 



521 



Fig. 425. 



cision (Fig. 426). The flaps are dissected up for a short 
distance, the ankle-joint is opened, disarticulation is effected, 
and the internal flap is carefully dissected from the bones. 

Other methods of amputation of the foot are sometimes 
employed, such, for instance, as that advocated by Han- 
cock, who has combined Pirogoff 's amputation with the 
subastragaloid method, bringing the sawed surface of the 
os calcis in contact with a transverse section of the astrag- 
alus. 

Hancock has advocated the propriety of amputating 
the foot without regard to the posi- 
tion of the tarsal joints, cutting the 
flaps of sufficient length and divid- 
ing the bones with a saw. 

Trlpier has also modified the sub- 
astragaloid amputation by leaving 
the upper part of the calcaneum, 
which he saws through on a level 
with the sustentaculum tali, and at 
right angles to the axis of the leg ; 
the external incisions are made as 
in Chopart's amputation. 

In the method advocated by Miku- 
licz the astragalus and calcaneum are 
removed, the ends of the tibia and 
fibula are sawed off, and the sawed 
surfaces of the scaphoid and cuboid 

are approximated to these, the Stump Union between calcaneum 
^. r , ■,. ,i o , n and tibia in Pirogoff 's am- 

resulting resembling the toot ot pes pu tation. (Hewson.) 
equinus. 




AMPUTATIONS OF THE LEG. 

The leg may be amputated at its lower, middle, or upper 
third, the rule being to save as much of the limb as pos- 
sible ; but as regards the application of prosthetic^ appa- 
ratus, I think the stumps resulting from amputations in 
the middle and upper thirds will be found more satisfac- 
tory. It is well also in sawing the bones to divide the 



522 AMPUTATIONS. 

fibula at a slightly higher point than the tibia. The 
circular, modified circular, oval, elliptical, long anterior 
flap, rectangular flap, antero-posterior flap, lateral flap, or 
external flap method may be employed. 

Circular Method. — A circular incision is made through 
the skin and connective tissue just above the malleoli, the 
cuff is dissected up for a sufficient distance, a circular 
incision of the tendons and muscles is next made, and the 
tissues being retracted, the bones are divided with a saw. 

Modified Circular Method.— In this method of anipu- 

Fig. 426. 




Incision in Roux's amputation. 

tation of the leg two oval flaps, either antero-posterior or 
lateral, of the skin and connective tissue are marked out 
by incisions. The flaps are then dissected up to the ends 
of the incisions, and a circular division of the muscles is 
made (Fig. 427, A). 

Elliptical Method. — In this method of amputation the 
incision is in the form of an ellipse ; its lower end crosses 
the heel below the insertion of the tendo-Achillis, and the 
upper end of the incision is about an inch above the ante- 
rior articular edge of the tibia (Fig. 428, B). 

Long Anterior Flap Method. — An anterior flap equal 
in length to the diameter of the ]eg at its base is marked 



AMPUTATIONS OF THE LEG. 
Fig. 427. Fm. 428. 



523 





Fig 427.— Amputation of the leg. A. Modified circular method. B. Reo 
tangular flap. C. Antero-posterior flap. The dotted lines indicate the levels 
at which the bones areto be sawn through. (Stimson.) _ 

Fig. 428. -Amputation of the leg. A. Long anterior flap. B. Elliptical flap. 
C. At upper third. (Stimson.) 

out bv a curved incision through the skin beginning at 
the posterior edge of the tibia on the inner side, a little 
below the point at which the bones are to be divided, and 
is carried over the leg to a point directly opposite over the 



524 



AMPUTATIONS. 



fibula (Fig. 428, A). The anterior muscles are divided 
transversely half an inch above the lower end of the flap, 
and are dissected from the bone to the base of the flap. 
The posterior flap is then made by entering the knife 
behind the bones at the point of the original incision and 
cutting directly outward. 

Rectangular Flap Method (Teale). — In this method 
of amputation of the leg an incision equal in length to 
half of the circumference of the leg is made from the 
point at which the bones are to be divided on one side 

Fig. 429. 




Amputation of the leg by lateral flaps. (Bryant.) 

of the leg, and is carried across the limb and back upon 
the opposite side to a point opposite the point of starting. 
The flap thus marked out is dissected up to its base, and 
a posterior flap of one-fourth the length is next cut by a 
transverse incision down to the bones, and is dissected back 
to the line of the origin of the first incision (Fig. 427, B). 
The long flap is next doubled back and its edges secured 
to the posterior flap, or the long flap may be cut from 
the posterior surface of the leg and the short flap from 
the anterior surface. 

Antero -posterior Flap Method. — A long anterior flap, 
including half of the circumference of the limb, may be 
cut from without inward, composed of skin, connective 
tissue, and muscles; and a short posterior flap, cut from 
within outward, may also be employed. This method is 
often employed in amputations in the upper portion of the 
leg (Fig. 427, C). 

Lateral Flap Method. — In the lower and middle thirds 



AMPETATIOSS AT TEE EXEE-JOIXT. 525 

of the leg the method of amputation by means of lateral 
skin flaps may be emploved with advantage. In this 
method an incision is made over the spine of the tibia, 
and an oval flap, embracing one-half of the circumference 
of the leg. composed of the skin and connective tissue, is 
dissected tip : starting from the same point, a similar flap 
is formed on the opposite side of the leg and dissected op ; 
the muscle- at the upper extremity of the flaps are next 
divided by a circular incision and the bones are divided 
with a saw i Fig. 429). 

External Flap Method iSedillot). — In this method of 
amputation of the leg the point of the knife is entered a 
finger's breadth external to the spine of the tibia and 
carried outward, grazing the fibula, and is brought out as 
far as possible to the inner side ; a flap three or four inches 
in length is then cut from within outward ; the extremities 
of the incision are next united by an incision across the 
inner side of the limb, involving the -kin only ; any re- 
maining muscular tissue is next divided and the bones are 
sawed. The long external flap is then brought over the 
ends of the bones and fastened to the edge- of the incision 
on the inner side of the limb. Professor Ashhurst modified 
this operation by cutting the long external flap from with- 
out inward, and made also a short internal flap in the 
same manner. By either method the resulting stump is a 
good one. with the ends of the bones covered by the tissues 
of the external flap. 

AMPUTATIONS AT THE KNEE-JOINT. 

Amputations at the knee-joint may be done either by 
the circular or elliptical incision, or by means of flaps, 
and may consist in simple disarticulations or sections 
through the condyles of the femur. 

Elliptical Method.— In this operation an incision 
crossing the spine of the tibia, five finger-breadths below 
the lower extremitv of the patella, is carried around the 
back of the les: three finger-breadths higher than in front : 
the tis^ue^ on the front of the leg are dissected up until 



526 



AMPUTATIONS. 



Fig. 430. 



the tendon of the patella is exposed ; the leg is then flexed 
and the ligament of the patella is divided ; the capsular 
ligament and the lateral and crucial ligaments are next 
severed, care being taken not to 
injure the popliteal vessels with 
the point of the knife. The tibia 
is next drawn forward, the knife 
is passed behind its posterior bor- 
der, and the remaining soft parts 
are divided from within outward. 
Anterior Flap Method.— In 
this method of amputation a long 
cutaneous flap is formed. The 
incision, beginning half an inch 
below the articulation, is carried 
five inches below the patella ; 
crossing the anterior surface of 
the leg, it is carried back to the 
condyle of the femur on the oppo- 
side side. This flap is dissected 
up, and the ligament of the patella 
divided and the disarticulation ef- 
fected. A short posterior flap, 
uniting the anterior incision one 
inch below its extremities, is next 
cut by transfixion or from without 
inward (Fig. 430, A). The patella 
is not removed. 

Amputation through the Con- 
dyles of the Femur.— In this 
amputation, which is known as 
Garden's amputation, an anterior 
flap, whose lower extremity is 
three finger-breadths below the 
patella, is cut and the disarticu- 
lation effected ; the posterior soft 
parts are divided, the patella re- 
moved, and the condyles next sawed through just above 
the edge of the articular cartilage (Fig. 430, B). 




Amputations at the knee- 
joint and lower third of the 
thigh. .4. Long anterior flap. 
B. Amputation through con- 
dyles. B' . Line of section of 
the condyles of the femur. C. 
Modified* flap at the lower 
third of thigh. (Stimson.) 



AMPUTATIONS OF THE THIGH. 



527 



Fig. 431. 



Lateral Flap Method. — In this operation an incision 
is made just below the patella, and is carried down the 
spine of the tibia for three inches, and is then carried 
backward to the middle of the leg at a point opposite the 
beginning of the incision ; a similar flap is cut on the 
opposite side of the leg, and the flaps dissected up to 
the line of the articulation. When this point is reached, 
the joint is opened and the disarticulation effected. The 
patella is not removed (Fig. 
431). 

Gritti's Amputation at the 
Knee-joint. — In this operation 
a long rectangular anterior flap 
is first cut and dissected up, 
and after the disarticulation 
has been effected the skin cov- 
ering the posterior surface of 
the knee is cut from within 
outward. The condyles of the 
femur are next removed by a 
saw above the edge of the ar- 
ticular cartilage, and the artic- 
ular surface of the patella is 

cutting forceps. The patella is next brought down, so 
that its sawed surface is in contact with the sawed surface 
of the condyles, and the flaps are brought together (Fig. 
432, A). 




Amputation at the knee-joint by 
lateral naps. (Smith.) 

removed by the saw or 



AMPUTATIONS OF THE THIGH. 

Modified Circular Method. — Two oval flaps of skin 
and connective tissue, the upper extremities of which are 
several inches above the condyles of the femur, are marked 
out bv incisions and dissected up, the muscles are next 
divided by a circular incision, and the bone is divided 

with a saw. 

Long Anterior Flap Method. — In this operation an 
incision is made on the anterior aspect of the thigh, 
marking out a flap whose length is equal to one-third, 



528 



AMPUTATIONS. 
Fig. 432. 




A. Gritti's amputation at the knee. A'. Lines of division of the hones. B. 
Amputation of the thigh, long anterior flap. B'. Division of the bone. C. Am- 
putation at the lower third of the thigh. C. Division of the bone. D. Disarticu- 
lation at the hip-joint. (Stimson.) 

and whose width at its base is equal to two-thirds, of the 
circumference of the limb. The anterior muscles are next 
divided obliquely upward and backward, so that the flap 
shall not be too thick, and the posterior muscles are cut 
transversely and the bone divided with a saw (Fig. 432, B). 
Amputation in the lower third of the thigh may also be 



AMPUTATIONS AT THE HIP- JO INT. 



529 



effected by employing a long anterior and a short posterior 
flap. The anterior flap is cut, its lower extremity extend- 
ing down to the lower edge of the patella, and after dis- 
secting up the skin and cellular tissue to the upper 
extremity of the patella the muscles are cut obliquely up 
to the point at which the bone is to be divided. A short 
posterior flap is next cut, and, the soft parts being retracted, 
the bone is sawed through (Fig. 432, C). 

Fig. 433. 




Amputation of thigh hy flaps cut by transfixion 



Transfixion Method — In amputations of the thigh the 
flaps may also be cut by transfixion, either lateral or 
antero-posterior flaps being: employed (Fig. 433). 

Amputation of the Thigh through the Trochanters. 
— "When, for any reason, it is inadvisable to amputate at 
the hip-joint, an amputation may be made through the 
trochanters, a long anterior and a short posterior flap being 
employed, with circular division of the muscles. 



AMPUTATIONS AT THE HIP-JOINT. 



In amputations at the hip-joint, it is important that 
provision be made for the control of hemorrhage during 
34 



530 AMPUTATIONS. 

the operation, and this is accomplished by compression of 
the femoral artery by the fingers of an assistant, or by the 

Fig. 434. 




Esmarch's elastic strap applied to control hemorrhage during amputation 
at the hip-joint. 

preliminary ligation of the femoral artery just below 
Poupart's ligament. Esmarclr's elastic strap may also 
be employed for the control of bleeding during amputa- 
tion at the hip-joint, the strap being applied in such a 
manner that it occupies the position of the turns of a 
spica-bandage of the groin (Fig. 434). 

DiefFenbach and Wyeth, to avoid hemorrhage, make 
first a circular amputation in the continuity of the thigh, 
and after controlling the hemorrhage disarticulate the 
head of the femur and remove it ; Jordan and Senn dis- 
articulate the head of the bone first through an external 
incision, and control the bleeding before the amputation is 
completed by passing an elastic tourniquet around the soft 
parts above the point where they are to be divided. 

The methods of amputation at the hip-joint are the 
oval, antero-posterior flap and lateral flap, and modified 
circular methods. 

Transfixion Method. — In this method the point of a 
long amputating-knife is thrust into the tissues about two 
finger-breadths below the anterior superior spinous process 



AMPUTATIONS AT THE HIP- JOINT. 



531 



of the ilium, and is pushed through the tissues, grazing 
the hip-joint, and brought out on the opposite side of the 
thigh close to the junction of the scrotum. The knife is 
next carried downward close to the bone, and an anterior 
flap of sufficient length is cut from within outward. This 
flap is held up by an assistant and the head of the bone 
disarticulated, and, the knife being passed behind the 

Fig. 435. 




Amputation at the hip-joint by antero- posterior 



(Holmes.) 



bone, a posterior flap of equal length is cut from within 
outward (Fig. 435). 

Guthrie's method of amputation at the hip-joint consists 
in cutting the flaps from without inward, a smaller knife 
being used for this purpose and the posterior flap being 
cut first. 

Modified Circular Method.— In this operation short 
antero-posterior flaps of skin and connective tissue are 
cut and dissected up, the muscles are divided by a circular 



532 AMPUTATIONS. 

incision at the level of the joint, and disarticulation of the 
head of the femur is next effected. 

Lateral Flap Method. — In this operation two flaps are 
cut from the inner and outer side of the thigh by trans- 
fixing, or by cutting from without inward and exposing 
the joint, which is opened and disarticulation of the head 

Fig. 436. 




Amputation at the hip-joint by external and internal flaps. (Bbya>t.) 

of the femur effected as in the preceding methods (Fig. 
436). 

Wyeth's Method of Controlling Hemorrhage in Amputating 
at the Hip-joint. — In amputating at the hip-joint by this 
method the hip to be operated upon is brought well over 
the edge of the table and the Esmarch bandage applied 
to the limb. Two stout steel pins, twelve or fourteen 
inches in length, are required : the point of one of these 
pins is passed through the skin one and a half inches 
below and slightly to the inner side of the anterior supe- 
rior spine of the ilium and carried through the tissues 
about half-way between the great trochanter and the spine 
of the ilium external to the neck of the femur, and its 
point is made to emerge just behind the trochanter; the 
second pin is made to enter the skin an inch below the 
crotch, internal to the saphenous opening, and its point is 
made to emerge about an inch and a half in front of the 
tuber ischii. The points of the pins are next protected 
with corks, and a long piece of rubber tubing or an Es- 
march elastic strap is wound tightly live or six times 



AMPUTATIOSS AT THE HIP-JOIST. 533 

about the limb above the fixation pins (Fig. 437). The 
Esmarch bandage should then be removed and a cir- 
cular incision of the skin and cellular tissue made five 
inches below the constricting band ; this cellulo-cutaneous 
cuff should next be reflected to the level of the trochanter 
minor ; a circular division of all the muscles should next 
be made at this point and the bone divided with a saw 
(Fig. 438'. The lar^e vessels should next be secured, 
and after this has been done the rubber tube should 
be removed, and any vessels which bleed should then be 

Fig. 437. 




Fins inserted and tube applied. 

tied. The exposed end of the femur is then grasped 
with bone forceps, and an incision is next made upon 
the outer side through the skin and muscles until the 
neck and head of the bone are exposed, and the disarticu- 
lation is accomplished. 

This method is now practised without first sawing the 
femur. The pins and elastic constrictor are applied as pre- 
viously described and a circular incision, including the skin 
and cellular tissue, is made around the thigh six inches 



534 



AMPUTATIONS. 



below the tip of the great trochanter and a cuff of skin and 
cellular tissue is dissected up (Fig. 439). A vertical in- 
cision is then made down to the bone from the outer side 
of the cutaneous incision to a point one inch above the 
great trochanter. The flaps thus formed are retracted and 
the bone is dissected out of its muscular bed. The capsule 
of the joint is then exposed and opened and the disartic- 

Fig. 438. 




Limb amputated and bone sawed. (Wyeth.) 



ulation is effected by adduction and rotatory movements 
of the limb. As soon as the head of the bone has been dis- 
articulated the posterior muscular attachments are severed 
and the limb is removed. The femoral artery and vein, 
the profunda, and descending branch of the external cir- 
cumflex should be ligated before the elastic constrictor is 



AMPUTATIONS AT THE HIP-JOINT. 



535 



removed. A number of muscular branches will after this 
require ligation. Drainage should be introduced and the 



Fig. 439. 




The needles and constrictor applied : circular and longitudinal incisions for 
skin flap. (Wyeth.) 



flaps approximated with sutures, and a copious gauze dress- 
ing should be applied. 



PAET VIII. 
EXCISIONS OR RESECTIONS 



EXCISION OF THE JOINTS. 

This operation consists in the partial or complete re- 
moval of the articular surface of the bones making up the 
joint. The term resection is sometimes used as synony- 
mous with excision, but it is usually employed to indicate 
the removal of a portion or the whole of the shaft of one 
of the long bones. Excisions or resections of joints and 
bones may be required on account of injury, disease, or 
anchylosis of a joint in faulty position. In the operation of 
excision of the joint the incision should be sufficiently free 
to permit of an inspection of the diseased portions of the 
joint, and it is preferable to remove the diseased articular 
surface of the bone with a saw ; small areas of diseased 
bone may be removed with the curette or gouge forceps. 
In performing excisions of joints in young subjects care 
should be taken to see that the epiphyseal cartilage is not 
encroached upon, for if this is removed the subsequent 
growth of the limb may be interfered with. The result 
desired in cases of excision of joints, in addition to 
removal of the diseased tissue, varies somewhat with the 
joint involved ; for instance, in a knee-joint anchylosis is 
desired ; in the shoulder, hip, elbow, and wrist, we wish 
to obtain a movable false joint ; when the latter condition 
is desired after excision, care should be exercised not to 
divide muscles or tendons, and as far as possible not to 
interfere with their attachments. When anchylosis is 

537 



538 



EXCISIONS OR RESECTIONS 



desired, the division of muscles or tendons is not a serious 
consideration : any injury to the principal arteries, veins, 
and nerve- should always be avoided. 




yarrzw-bladed saw. 
Fig. 443. 




Chain-saw. 



The instrument? required for the excision of joints are 
a stout scalpel (Fig. 440 . probe-pointed knife, and ex- 



INSTRUMENTS FOR EXCISIONS. 
Fig. 444. 




Lion-jawed forceps. 

Fig. 445. 




Retractor. 
Fig. 446. 



539 



Elevator. 
Fig. 447. 




Bone-cutting pliers. 
Fig. 448. 




Knife-bladed forceps. 
Fig. 449. 




Periosteotome. 



540 



EXCISIONS OR RESECTIONS. 



Fig. 450. 



cision saw with reversible blade (Fig. 441), Darrow-bladed 
saw (Fig. 442) or chain-saw (Fig. 443), strong lion-jawed 
forceps (Fig. 444), retractors (Fig. 445), an elevator (Fig. 
446), heavy bone-cutting pliers (Fig. 447), knife-bladed 
forceps (Fig. 448), and a periosteotome (Fig. 449). 

Excision of the Shoulder -joint. — In excising this 
joint, the arm is abducted and rotated inward, and a 
straight incision is made extending from the beak of the 
coracoid process down the arm in the line of the bicipital 
groove ; this incision may be supplemented by a short, 
transverse incision from the upper edge of the first inci- 
sion to the acromion proc- 
ess (Fig. 450). As the in- 
cision is deepened the fibres 
of the deltoid muscle are 
divided in this line, and the 
capsule of the joint is ex- 
posed and divided along the 
outer edge of the tendon of 
the long head of the biceps 
muscle ; this tendon is held 
to one side, the capsule of 
the joint is freely opened, 
and the muscles inserted 
into the tuberosities of the 
Excision of the shoulder-joint, a. humerus are divided with 

Regular incision. B. Supplementary „ ,-,„^u^ ,~^,~4- A 1 'C 1 

incision. (Stimson.) a probe-pointed knife and 

freed with an elevator ; the 
head of the bone may then be removed by sawing across 
the surgical neck of the bone with a narrow metacarpal 
saw or chain-saw, and the sawed surface of the humerus 
rounded off with bone forceps. The end of the bone is 
then replaced in the glenoid cavity and the wound drained 
and closed. 

Resection of the Humerus. — A portion of the humerus 
may require resection for injury or disease. The incision 
should be made upon the outer side of the bone and car- 
ried down in the muscular interspaces on a line with the 
shaft, care being taken to avoid injury of the musculo- 




RESECTION OF TEE RADIUS OR ULNA. 541 

spiral nerve, which, as it passes around the posterior sur- 
face of the humerus, lies close to the bone between the 
humeral heads of the triceps muscle at a point correspond- 
ing to the deltoid insertion anteriorly — i. e., about the 
centre of the shaft of the humerus. This nerve should be 
isolated and held aside, and the bone exposed. After 
separating the periosteum as completely as possible, if the 
shaft of the bone is diseased, it should be removed by 
dividing it in the middle with a saw or forceps, and 
removing each fragment as far as the upper and lower 
epiphyses, or the upper or lower portion only may require 
removal. 

Excision of the Elbow-joint. — In excising this joint, 
the forearm is slightly flexed and a longitudinal incision 
is begun about two inches above the olecranon process and 
a little to its inner side, and carried about three or four 
inches down in the line of the ulna (Fig. 451); the tissues 
are then divided down to the bones, and the ulnar nerve 
is dissected from its groove behind the inner condyle of 
the humerus and held aside by a retractor ; the tendon of 
the triceps is divided, and its attachment to the fascia 
and periosteum over the olecranon process is separated 
with an elevator or periosteotome and turned downward ; 
the joint is next opened and the lateral ligaments divided 
as the forearm is flexed upon the arm. The upper part 
of the ulna and the head of the radius are freed with a 
probe-pointed knife and removed with a narrow-bladed 
saw, care being taken in making the section of the radius 
to divide its neck so that the attachment of the biceps 
muscle is not interfered with. The condyles of the humerus 
are next freed and removed with a saw. In freeing the 
bones at the anterior portion of the joint, great care should 
be used to avoid injury of the brachial artery and vein and 
the median nerve. 

Resection of the Radius or Ulna. — The radius or 
ulna may be resected, either entirely or partially, by mak- 
ing an incision upon the back of the forearm over the 
bone to be removed ; the bone being exposed, the perios- 
teum is separated with an elevator and the bone divided 



542 



EXCISIONS OR RESECTIONS. 



with a saw, and each fragment lifted and separated from 
its muscular attachments up to the point where it is 
desired to remove it (Fig. 452). If the articular surface 
of the bone is to be removed, the disarticulation should be 
made carefully with a strong scalpel or a probe-pointed 
knife, care being taken to avoid injury of the vessels and 
nerves lying upon its palmar surface. 

Excision of the Wrist. — The wrist is covered on its 
posterior and lateral aspects with skin, fascia, and tendons ; 

the relative position of the 
Fig. 451. bones entering into the articu- 

lation may be seen in the ac- 
companying figure (Fig. 453). 



jig. 45' 




II ! \ 

Incision for excision of the elbow- Resection of the lower end of the radius. 
joint. (Stimson.) 

The wrist-joint may be excised by making a dorsal 
incision, beginning at the middle of the ulnar border of 
the second metacarpal bone, and carried upward about 
four inches, crossing the ulnar edge of the tendon of the 
extensor carpi radialis brevior, and splitting the dorsal 
ligaments of the wrist between, the tendons of the extensor 
secondi internodii and the extensor of the forefinger (Fig. 
454). The incision should be carried down to the bone 
and the soft parts and tendons dissected loose with an 
elevator. By flexing the hand, the first row of the carpus 
is made to present in the wound, and the scaphoid is sepa- 



RESECTION OF THE RADIUS OR ULNA. 543 

rated from the trapezium and removed ; the semilunar and 
cuneiform should next be removed ; the trapezium and 
pisiform should be left if possible. In removing the 
second row of carpal bones, the knife should be passed 
between the trapezium and the trapezoid and then into the 
carpo-metacarpal joint, and by cutting the ligaments on 
the dorsal side of the ends of the metacarpal bones the 

Fig. 453. 



Articulations of the wrist-joint. (Lister.) 

trapezoid, os magnum, and unciform may then be removed. 
The lateral ligaments are next carefully divided, and the 
articular ends of the radius and ulna removed with a saw; 
the ends of the metacarpal bones should next be removed 
with a saw or bone-forceps. 

Mynter's Method. — This consists in making an incision 
on the dorsum of the hand extending from the radius down- 
ward between the second and third metacarpal bones and 
through the palm, splitting the hand as high as the super- 
ficial palmar arch, thus entering the wrist between the trap- 
ezoid and os magnum and between the scaphoid and semi- 
lunar bones. By this method it is possible to excise the 



544 



EXCISIONS OR BESECTIOXS. 



Fig. 454. 



carpus without injury to the palmar arches and palmar 
bursa?. 

Resection of a Metacarpal Bone. — A metacarpal bone 
may be resected bv making a longitudinal incision on the 
back of the hand over the bone to be removed. The 

incision should extend 
from one articular end 
to the other, and the ex- 
tensor tendon when ex- 
posed should be held to 
one side by retractors ; 
the periosteum should 
next be separated as far 
as possible, and when the 
bone has been fully ex- 
posed it may be removed 
by dividing it in the 
middle with bone-forceps 
and then disarticulating 
each fragment ; or the 
articular ends may be 
freed and the bone re- 
moved in one piece (Fig. 
455). 
Excision of Meta- 
carpophalangeal Joints or Interphalangeal Joints. — 
The metacarpophalangeal joint is exposed by a longitudi- 
nal incision over the dorsal surface of the knuckle ; the 
extensor tendon being exposed and held to one side, the 
lateral ligaments are divided. The articular ends of the 
bones are then exposed and removed with a metacarpal 
saw or with bone-forceps (Fig. 456). In excising the 
interphalangeal joints, the incision is usually made upon 
the side of the joint, and when the articular surfaces of 
the bone have been exposed they are removed with a small 
saw or forceps. 

Excision of the Clavicle. — The clavicle is excised by 
making an incision over the bone from one articulation to 
the other, which is carried directlv down to the bone ; the 




IliMw 



Incision for excision of the wrist-joint. 
(Stimson. 



RESECTION OF THE BIBS. 



545 



periosteum is then separated, and the shaft of the bone may 
be divided at the middle and each fragment raised and 
disarticulated ; or the bone may be disarticulated at one 
extremity, then raised up and freed from its adherent 
tissues, and disarticulated at the other extremity. In 
disarticulating the sternal articulation of the clavicle 
(Fig. 457), a probe-pointed knife should be used, and 
great care should be exercised to avoid injury of the 
important vessels and nerves which lie in close proximity 
to it. 

Resection of the Ribs. — In this operation the incision 

should correspond in length 
Fig. 455. and direction with the por- 

tion of bone to be removed, 
and may be crossed at each 

Fig. 456. 





Resection of a metacarpal bone. 



Excision of a metacarpophalangeal 
joint. 



end by a short transverse incision. The tissues overlying 
the rib are then dissected loose, the periosteum is separated 
as far as possible, the rib is divided with bone-forceps at 
two points, the fragment is grasped with forceps, and the 
attachments to the under surface of the rib are separated 
with an elevator. Care should be taken to avoid opening 
the pleural cavity. 

Estlander's Operation. — This operation is* employed in 
cases of empyema, and consists in resecting the portions 

35 



546 EXCISIONS OR RESECTIONS. 

of several adjoining ribs to allow the chest-wall to sink 
inward and unite with the pulmonary pleura. A rectan- 
gular or oval flap is marked out by an incision, corre- 
sponding to the portion of the ribs to be removed, includ- 
ing all of the tissues external to the ribs. The flap is 
dissected up, and portions of several ribs are divided with 
bone-forceps or a saw, and removed with forceps. If the 
costal pleura is very thick, to expose the cavity so as to 
permit of free drainage and allow the chest-wall to sink 
in, it may be cut away over a part of the area from which 




Resection of the sternal end of the clavicle. 

the ribs have been resected ; one to four inches of three to 
six adjoining ribs may be removed. 

Resection of the Sternum. — This operation is per- 
formed by making a longitudinal incision over the portion 
of the bone to be removed ; the periosteum is separated, 
and the diseased portion of the sternum is then carefully 
freed with an elevator and removed. 

Excision of the Scapula. — To excise this bone, an 
incision should be made along the whole length of the 
spine of the' scapula, and from its posterior extremity 
two other incisions should be made, one running about an 






EXCISION OF THE HIP. 



547 



Fig, 458. 



inch or two above, and the other passing down the poste- 
rior border of the bone to its inferior angle (Fig. 458); 
the flaps thus made are loosened by separating the muscles 
attached to the outer surface of the bone. The attach- 
ments of the deltoid and trapezius muscles to the acromion 
and spine of the scapula are separated, and the lower angle 
is freed by detaching the teres major and serratus magnus; 
the bone is then raised and the subscapulars muscle 
detached from below upward. The neck of the scapula 
should be divided with a chain-saw or bone-forceps ; the 
acromion is next separated 
from the clavicle, and the 
scapula turned upward, the 
joint being opened from be- 
low. The coracoid process 
should be separated from its 
muscular and ligamentous at- 
tachments, or may be divided 
with a saw and left in place. 
In clearing the supraspinous 
fossa, care should be taken 
not to injure the suprascap- 
ular nerve in the suprascap- 
ular notch ; it should be raised 
with the periosteum and its 
fibrous sheath. 

Excision of the Hip. — 
In excising the hip-joint, a 
curved or angular incision 
is made from a point about 
three inches below the crest 
of the ilium and about the 

same distance behind the anterior superior spine of the 
ilium, which should be carried downward over the great 
trochanter in the line of the femur for about five or six 
inches (Fig. 459) ; the soft parts are dissected from the 
great trochanter and upper part of the shaft of the femur, 
and the capsule of the joint opened. While an assistant 
rotates the thigh inward and outward, the muscles attached 




Incision for excision of the 
scapula. (Stuison.) 



548 



EXCISIONS OR RESECTIONS. 



to the trochanters are shaved off close to the bone : the 
neck of the femur is next freed by the use of a knife and 
elevator ; the thigh is adducted and pushed upward, and 
the head and neck of the bone are made to project from 

the wound. A transverse 
Fig. 459. section of the bone is 

\ \ then made with a saw 

just below the great 

Fig. 460. 





Incision for excision of the hip-joint. 

(Stemson.) 



Incision for excision of the 
knee-joint. A. Curved incision. 
B. Angular incision. Stqison.j 



trochanter. In some cases it is difficult to remove the 
head of the bone, which may be anchylosed firmly to the 
acetabulum; here the bone may first be divided with a 
chain-saw passed around the femur just below the great 
trochanter, or may be divided with a chisel, the head and 
neck of the bone afterward being removed with a gouge 
or bone-forceps. 

Anterior Excision of the Hip. — In this method of excis- 
ing the hip-joint, an incision is made upon the front of the 
thigh over the joint, beginning half an inch below the 
anterior superior spine of the ilium, and is carried three 






EXCISION OF THE KNEE-JOINT. 549 

or four inches downward and a little inward ; as the inci- 
sion is deepened the tensor vaginae femoris and the glutei 
muscles are exposed, and should be drawn to the outer 
side, the sartorius and rectus muscles are held to the 
inner side and the neck of the femur exposed ; the neck of 
the bone is then divided with a metacarpal saw or Adams' 
saw, the diseased portion of the bone is next grasped with 
strong sequestrum forceps, and by the use of these and an 
elevator the head of the bone is removed. 

Excision of the Knee-joint. — The knee-joint is ex- 
cised by making an incision which begins at the inner 
side of the limb over the inner condyle of the femur, and 
is carried over the front of the knee just below the 
patella to a corresponding point upon the external condyle 
of the femur (Fig. 460, A), or by an angular incision 
(Fig. 460, B). The flap thus formed is dissected up to a 
point corresponding with the upper edge of the patella, 
the ligamentum patellae is then cut through, the leg is 
slightly flexed, and the joint is opened ; the lateral liga- 
ments are then divided, and by flexing the leg upon the 
thigh the joint is freely exposed. The semilunar cartilages 
are next removed and the condyles of the femur are freed ; 
a narrow-bladed saw is placed under the condyles and a 
transverse section of the condyles is removed ; the head 
of the tibia is next cleared, and a transverse section of this 
bone is also removed with a saw. The patella may be 
removed before excising the ends of the bone, or, if anchy- 
losed to the condyles, may be removed with the section 
of bone which removes a portion of the condyles. In 
excising the knee-joint in young persons, care should be 
taken to remove only so much bone as may be done 
without encroaching upon the lines of epiphyseal carti- 
lages, as removal of the epiphyseal cartilage would inter- 
fere with the subsequent growth of the bones. 

Arthrectomy of the Knee-joint. — This operation is 
employed as a substitute for the operation of excision in 
disease of the knee-joint, and is performed by exposing 
the joint by an incision similar to that employed in excis- 
ion. The ligamentum patellae is divided and the patella 



550 



EXCISIONS OR RESECTIONS. 



is reflected with the skin flap. When the joint has been 
freely exposed, the diseased articular cartilages, semilunar 
cartilages, crucial ligaments, and synovial pouches are 
removed by the use of the knife or scissors and the 
curette ; if the surface of the bone is found to be carious, 
it is removed by the curette or gouge. After the joint 
has been thoroughly cleared of diseased tissue it is irri- 
gated, the divided ligamentum patellse is sutured with 

Fig. 461. 




Resection of lower end of the fibula. 



several strands of chromicized catgut or silk, and the 
wound is drained and closed. 

Excision of the Patella.— The patella may be excised 
by making a longitudinal or crucial incision ; the perios- 
teum is carefully separated from the bone, and the latter 
is grasped with strong forceps and dissected free from its 
attachments upon the under surface. The knee-joint is 
generally opened in removing the patella, unless removal 
of the bone be undertaken for necrosis or caries, when it 



EXCISION OF THE ANKLE-JOINT. 



551 



is possible to accomplish its complete removal without 
opening the joint. 

Resection of the Tibia or Fibula. — In resecting the 
tibia or fibula, the bones may be exposed by a longitudinal 
incision over the bone to be removed, and after the shaft 
of the bone has been exposed and the periosteum separated 
as completely as possible, the shaft 
of the bone may be divided at its Fig. 462. 

middle, and each fragment grasped 
with forceps and dissected up, and 
removed at its epiphyseal junction 
(Fig. 461). 

Excision of the Ankle-joint. — 
In excising the ankle-joint, an in- 
cision is made at a point two inches 
above the external malleolus, and 
carried downward over the fibula 
to the tip of the external malleolus ; 
it is then curved slightly upward 
toward the dorsum of the foot (Fig. 
462), care being taken that the in- 
cision does not extend so far forward 
as to endanger the extensor tendons 
or the dorsal artery. The bone is 
exposed in this incision and the 
periosteum is separated and turned 
aside ; the peroneal tendons are next 
exposed and held to one side by re- 
tractors ; the external malleolus is 

next divided by bone-forceps and removed, and the astrag- 
alus exposed. The upper articulating surface of the as- 
tragalus is next removed with bone-forceps or a saw, or 
the whole bone may be removed. The foot is next 
inverted and the end of the tibia cleared with a probe- 
pointed knife, care being taken not to injure the pos- 
terior tibial arterv, nerve, or vein ; and when the artic- 
ular surface has* been freed, it is removed with a saw 
or bone-forceps. The articular end of the tibia may 
be exposed by making an additional incision upon the 




Incision for excision of the 
ankle-joint. (Stimson.) 



oo : 



EXCISIONS OR RESECTIONS. 



inner side of the ankle over the internal malleolus if 
desired. 

Excision of the Astragalus. — In excising the astraga- 
lus, a semilunar incision is made upon the outside of the 
ankle-joint, very similar to that employed in excising the 
ankle : the external lateral ligaments are divided with a 
probe-pointed knife, and the astragalus is exposed by 
forcibly inverting the foot : the bone is then seized with 
strong forceps, its ligamentous attachments are divided 
with a probe-pointed knife, and it is removed. 

Excision of the Os Calcis. — An incision is made at 
the level of the upper part of rhe bone, beginning at the 
inner border of the tendo-Achilles. dividing this tendon 
and passing around the back and outer surface of the foot 
to the base of the fifth metatarsal bone ; a short incision is 

then made at the anterior end 
of the first incision and car- 
ried down to the sole of the 
foot : the bone is exposed and 
held by forceps : the flap thus 
formed, which includes the 
peronei tenduns. is then sep- 
arated from the bone, and 
the cuboid ligaments are cut 
and also the interosseous liga- 
ment between the as calcis 
the bone is removed with 




Incision for resection of the 
metatarsal bone of the sn*eat 
toe -MITHJ 



and the astragalus. 
forceps. 

Resection of the 
metatarsal bones mav 



and 



Metatarsal Bones. — Any of the 
be resected by an incision on the 
dorsum of the foot over the bone to be removed : the 
bone is exposed, the extensor tendons being held aside by 
retractors : the bone is disarticulated at either end or is 
cut in its middle, and each fragment dissected up and 
removed at its articulation. The metatarsal bone of the 
great toe is exposed by making a curved incision over that 
bone on the inner side of the foot (Fig. 463). 

Excision of the Coccyx. — -In excising the coccvx. the 
finger is passed into the rectum and the position of the 



EXCISION OF THE UPPER J A W. 



553 



bone determined ; a longitudinal incision through the skin 
and fibrous tissues covering the coccyx is made from a 
point about- a quarter of an inch above its upper limit, 
and is carried down to a little below its lower extremity. 
This incision may be supplemented with a transverse in- 
cision. The sacro-coccygeal articulation is then opened ; an 
elevator is next introduced into the articulation and the 
bone is raised up and grasped with forceps. It should 
then be freed from its lateral attachments, and those upon 
its anterior surface, with the knife and elevator. 

Excision of the Upper Jaw. — In excising one-half of 
the upper jaw, the incision is begun half an inch below the 



Fig. 464. 



Fig. 465. 




Incision for excision of the upper jaw. 



Incision for excision of the 
lower jaw. 



inner can thus of the eye, and is carried downward along 
the line of junction of the nose and cheek, along the course 
which limits the aire nasi, and longitudinally to the sep- 
tum, and then down through the free border of the lip ; it 
is also advisable to carry the incision along the lower edge 
of the orbit outward over the malar bone (Fig. 464); the 
flap being dissected away from the surface of the bone, a 
small, narrow metacarpal saw is then applied to the floor 
of the nostril until a deep groove is made ; the soft palate 



554 EXCISIONS OB RESECTIONS. 

and the tissue covering the hard palate are next divided 
from within the mouth with a strong knife ; one or two 
incisor teeth should be removed, and one blade of a pair 
of strong bone-forceps introduced into the floor of the 
nose in the line of the saw incision, the other blade is 
introduced into the mouth in the line of the division of 
the structures of the palate, and the bone divided. The 
malar bone is next divided with a saw or forceps, and, 
finally, the blades of a strong pair of bone-cutting forceps 
are introduced, one into the nostril and the other at the 
edge of the orbit, the important structures of the orbit 
being held upward with a retractor, and the inner angle 
of the orbit is cut across ; the superior maxillary bone is 
then grasped with strong, lion-jawed forceps and twisted 
out, any band of tissues which holds it being divided with 
the knife or scissors. 

Excision of the Lower Jaw. — Partial or complete 
excision of the lower jaw may be practised. 

Excision of the Ramus and Half of the Body of the Lower 
Jaw. — The incision should be made from a point just below 
the free border of the lip over the symphysis, and carried 
down to the lower border of the jaw, and from this point 
it is carried along the ramus to the lobe of the ear (Fig. 
465); the flap is then dissected up, separating the mas- 
seter muscle from the bone as far as possible without 
opening the cavity of the mouth ; an incisor tooth is next 
drawn and the bone is sawed through near the symphysis ; 
the jaw is then seized with forceps and drawn downward 
and forward and denuded upon its inner surface. The 
insertion of the temporal muscle into the coronoid process 
is divided, the condyle of the jaw is disarticulated from 
the glenoid cavity, and the remaining soft parts carefully 
detached with a knife or elevator. The facial artery and 
the inferior dental nerve and artery are necessarily divided 
in removing this portion of the jaw. 

Partial Excision of the Lower Jaw or Alveolus. — The re- 
moval of a portion of the alveolar process of the jaw may 
often be accomplished through the mouth without the aid 
of a cutaneous incision. The condyle of the jaw may be 



OSTEOTOMY. 



555 



excised by making an incision close in front of the tem- 
poral artery and carrying it forward along the zygoma 
for an inch and a half; the tissues being divided and the 
bone exposed, a second incision involving only the skin is 
then carried from the centre of the first directly down- 
ward for about an inch ; the soft parts are next carefully 
separated with a knife and elevator from the margin of 
the zygoma and outer surface of the joint and drawn 
downward with a retractor, to prevent injury of the parotid 
gland, nerves, and vessels. The neck of the condyle is 
then cleared by working around it in front and behind 
with a director, keeping close to the bone to avoid injury 
of the internal maxillary artery. A chain-saw is then 
passed around the neck of the bone, which is divided, and 
the condyle is seized with forceps and removed with an 
elevator or gouge. 

OSTEOTOMY. 

This operation consists in dividing the bones with a saw 
or osteotome, and is employed to correct deformities of the 
bones or joints. 

Fig. 466. 




Adams's saw. 



Fig. 467. 




The instruments employed are a saw with short cutting 
surface, Adams's saw (Fig. 466), or osteotomes (Fig. 467) ; 
a heavy mallet is used to drive the osteotome through the 



556 



EXCISIONS OR RESECTIONS. 



Fig. 468. 



bone. Osteotomy is often employed to correct deformi- 
ties of the hip following coxalgia, and here the femur is 
divided either at the neck, Adams's operation, or just below 
the trochanters. Gant's operation. 

Osteotomy of the Femur below the Trochanters. — 
A puncture is made with a bistoury on the outer side of 
the femur just below the great trochanter, and is carried 
down to the bone; the blade of the saw is then introduced 
and the femur divided from before backward. The femur 
may also be divided in this position with an osteotome. 

Osteotomy for Knock-knee. — 
The operation employed to correct 
this deformity is a transverse section 
of the femur above the condyles 
(Fig. 468). In the operation of 
supracondyloid osteotomy the knee 
is flexed and supported on a sand- 
bag. A longitudinal incision one 
inch in length is made half an inch 
anterior to the tendon of the ad- 
ductor magnus and a finger-breadth 
above the internal condyle ; the knife 
is carried down to the bone, and be- 
fore it is withdrawn an osteotome is 
introduced and its edge turned so as 
to divide the bone transversely. The 
section of the bone is accomplished 
by the use of the osteotome and 
mallet. After the bone has been 
divided, the deformity is corrected, 
the wound closed, and the limb put 
up in a plaster-of-Paris dressing in the corrected position. 
Osteotomy for Bowlegs.— To correct this deformity, 
the tibia and fibula are divided at the point of greatest 
bowing with an osteotome. The fibula is divided first 
with an osteotome entered through a puncture over the 
fibula, and next the tibia is divided in the same manner. 
The bones being divided, the deformity is corrected and 
the limb put up in a plaster-of-Paris dressing in the cor- 




A. Epiphyseal line. C. 
Line of bone section in 
supracondyloid osteotomy. 



TREPHINING THE SKULL. 



557 



rected position. Osteotomy may also be employed to cor- 
rect deformities in other bones, or for the deformity result- 
ing from fractures united in faulty position. 



TREPHINING THE SKULL. 

This is an operation in which a disk of bone of the 
skull is removed by a circular saw or trephine to expose 
the membranes and the brain. If a wound is already 
present in the scalp, exposing the skull, as in the case of 
compound fracture of the skull, it is exposed and bared, 
so that the crown of the trephine may be placed fairly on 
the bone ; if no wound exists, a U-shaped flap is made, 
including all the structures down to the 
bone. The base of the flap should be Fig. 469. 

so situated as to contain a sufficient 
blood-supply, and the flap should be 
so planned as to favor drainage from 
the wound. When the bone has been 
exposed, the trephine is placed with 
the centre pin projecting about one-six- 
teenth of an inch, and the instrument 
is turned from right to left until a groove 
is made in the bone ; the trephine is 
then removed, and the centre pin is 
raised so that as the teeth of the tre- Trephine, 

phine approach the inner table of the 
skull the point of the centre pin will not injure the 
membranes or brain. The instrument is then reapplied 
and worked cautiously as the groove in the bone is deep- 
ened. When the dip'loe is reached, there is usually some 
bleeding from the wound, and as the trephine approaches 
the inner table of the skull it should be manipulated with 
great care, and when the resistance is felt to diminish at 
any one part of the bone the trephine is made to cut at 
other points of the bone where resistance is still apparent. 
When the disk is completely cut through, it may be lifted 
out in the crown of the trephine or may be removed with 
forceps or an elevator. If the opening in the skull has to 




558 



EXCISIONS OB RESECTIONS. 



be enlarged to obtain greater exposure of the membranes 
or bxain, it may be done very satisfactorily with a form 
of rongeur forceps. 

A portion of the skull may also be removed by the use 
of the gouge and mallet; the gouge is generally preferred 
to the trephine in opening the mastoid cells. 

Fig. 470. 




1. Trephine opening for mastoid antrum. 2. For abscess from otitis media. 
3. To expose cerebellum. 4, 5. For middle meningeal hemorrhage. A. Lateral 
sinus. B and C. Limit of up and down variation. (Stimson.) 



When the trephine is applied to expose the seat of hem- 
orrhage from the middle meningeal artery, or hemorrhage 
from the lateral sinus, or an abscess from middle-ear dis- 
ease, or to open the mastoid antrum, the positions for the 
application of the trephine are indicated in Fig. 470. 



TREPHINING THE ANTRUM OF HIGHMORE. 559 

Osteoplastic Resection of the Skull. — In this opera- 
tion for exposing the membranes of the brain, a portion 
of the skull having the soft parts attached is turned 
aside, so that it may subsequently be replaced and sutured 
in its original position. The operation is frequently 
employed to expose the ganglia at the base of the brain 
and in the removal of tumors of the brain. A horseshoe- 
shaped incision is made, and the edges are allowed to retract 
(Fig. 471). A groove is next cat through the bone, fol- 
lowing the line to which the skin flap has retracted, with 
a chisel or with a circular saw run by a dental engine or 
electric motor. The line of division of the bone should 
be oblique, so that the outer table of the flap rests upon 
the inner table of the skull when the bone flap is turned 
back into place. The base of the bone flap is then partly 
divided with the chisel, with as little disturbance of the 
soft parts as possible, and the remaining bone in the base 
of the flap is broken and the flap turned back, the scalp 
acting as a hinge (Fig. 472). 

QiglVs wire saic may be used in operating upon the 
skull. Two small trephine openings are made, and a flat 
director passed into one of the openings, to separate the 
dura on a line between them, and the wire saw drawn 
through this space by a thread attached to a flexible silver 
probe. The bridge of bone is then divided by the saw. 
Any desired amount of bone can be removed by making 
three or four trephine openings and sawing between them. 

If the osteoplastic flap method is employed, the skin is 
left undivided on one side and adherent to the bone flap, 
and the saw is made to cut the bridge of bone between 
the trephine openings obliquely, so as to bevel the edges 
of the flap. 

An instrument for osteoplastic resection or trephining 
of the skull, which accomplishes the object more rapidly, 
has recently been introduced by Dr. T. C. Stellwagen, Jr. 

Trephining the Antrum of Highmore. — The antrum 
may be opened by extracting the first or second molar tooth 
and deepening its socket with a small gouge or bone drill. 

The antrum may also be opened through the mouth, to 



560 



EXCISIONS OR RESECTIONS. 
Fig. 471. 




Fig. 472. 




Osteoplastic resection of the skull. (After Treves.) 



LAMINECTOMY. 561 

avoid a scar upon the face, by the use of a small trephine 
or bone-gouge ; the gingivo-labial fold is divided up to a 
point just below the infra-orbital foramen, the trephine 
is placed here, and a disk of bone removed, opening the 
antrum. 

Trephining the Frontal Sinus. — This sinus may be 
opened by a trephine or bone-gouge. An incision is made 
from the centre of the supra-orbital ridge to the median 
line above the root of the nose. The tissues are divided 
down to the periosteum ; this is incised and turned aside, 
the trephine or gouge is placed at the centre of the incision 
near the inner edge of the supra-orbital ridge and a disk 
of bone is removed, exposing the frontal sinus. 

LAMINECTOMY. 

This operation, which consists in exposing and cutting 
away the arches of the vertebrae, to secure a free exposure 
of the spinal canal and cord, is resorted to in cases of 
fracture of the vertebrae, tumors of the spinal cord, and 
in cases of tuberculosis of the spine in which there is 
marked deformity with paralysis, the object being, as a 
rule, to relieve the spinal cord from pressure. A straight 
incision, four or five inches in length, is made over the 
point at which the arches of the vertebrae are to be 
removed, and the skin, muscles, and fascia are divided, 
and the spinous processes and arches of the vertebrae are 
laid bare. Then with strong bone-forceps the arches of 
the vertebrae on each side are divided, care being taken to 
avoid injuring the dura. A better method is the forma- 
tion of a lateral flap by an incision over the arches upon 
one side, the periosteum and muscles being reflected to the 
base of the spinous processes, the latter then being divided 
with bone-forceps or chisel and lifted up in the flap, the 
dissection of which is continued toward the other side 
until the arches are exposed from end to end. The latter 
are then cut away. It is often necessary to remove several 
laminae if any considerable amount of the spinal cord or 
canal is to be exposed. 

36 



562 OPERATIONS UPON NERVES. 

OPERATIONS UPON NERVES. 

Neurotomy. — ^Neurotomy is an operation in which the 
nerve-trunk is exposed and a section made through the 
nerve. As in the case of ligation of vessels, it is most 
important that the operator should have an accurate 
knowledge of the anatomical relations of the nerves and 
the surrounding structures. The nerve is exposed by an 
incision similar to that for the exposure of an artery for 
the application of a ligature. 

Nerve-stretching, or Neurectasy. — In the operation 
of neurectasy, or stretching of nerves, the nerve is exposed 
and isolated and is lifted upon a blunt hook or retractor ; 
or, in case of the larger nerves, is hooked out of the wound 
by the finger, and is thoroughly stretched and replaced in 
the wound, and the latter closed with sutures. 

Neurectomy. — In this operation the nerve is exposed 
and a portion of the nerve is excised. 

Suture of Nerves, or Neurorrhaphy. — In bringing 
into apposition the ends of divided nerves, primary or sec- 
ondary sutures may be employed. The material employed 
for sutures should be fine silk or fine chromicized catgut. 
In using primary sutures, the suture in the case of the 
smaller nerves should be passed through the sheath and 
substance of the nerve, and in the larger nerves two sets 
of sutures may be used, one passing through the substance 
of the nerve, the other through the sheath. 

Nerve-grafting. — In employing secondary sutures to 
unite the divided ends of nerves when there has been a 



Fig. 473. 




Nerve-grafting. (Willard.) 



loss of substance in the nerve, or there has been so much 
retraction of the nerve that it is impossible to bring the 
ends together, nerve-grafting may be made use of; the 
ends of the nerve being freshened, a section of a fresh 



NEUROPLASTY. 563 

Derve from an amputated limb or animal is sutured to the 
ends of the divided nerve to fill up the gap, as seen in 
Fig. 473. 

Nerve-implantation. — This operation consists in sutur- 
ing a healthy nerve, either in whole or in part, to a para- 
lyzed one. Implantation is practised by inserting the cut 
end of a nerve into an incision made into the sheath of an 
adjacent nerve and securing it in this position by sutures. 
Both the upper and lower ends of a nerve may be implanted 
into a neighboring nerve in this manner. 

Neuroplasty. — Another method of lengthening the 
ends of a divided nerve, known as neuroplasty, may be 
employed where the ends cannot be brought into apposi- 
tion by the ordinary method ; in this method flaps are 
made for the nerve in the same way as in the lengthening 
of shortened tendons, and the ends of the flaps are sutured 

Fig. 474. 



Neuroplasty. (Willard.) 

together, as seen in Fig. 474. Sutwes a distance may 
also be employed, as in the case of the separated ends of 
tendons. 

The following incisions are given to expose the nerves 
for some of these various operations : 

The Supra-orbital Nerve. — This nerve is exposed at the 
supra-orbital notch at the junction of the middle and 
inner thirds of the supra-orbital arch. An incision is 
made one and a half inches in length, parallel to the eye- 
brow (Fig. 475, A and B), and is carried down to the 
bone ; the nerve is exposed and grasped with forceps, and 
resected or stretched as may be desired. 

The Superior Maxillary Nerve. — A vertical incision is 
made along the inner side of the nose from the bony ridge 
of the nasal process of the superior maxillary bone to the 
ala of the nose ; a second incision is begun at the upper 
part of this incision and carried outward along the lower 
margin of the orbit beyond its centre (Fig. 475, C); the 



564 



OPERATIONS UPON NERVES 



lower flap is dissected up and the infra-orbital nerve ex- 
posed. The upper flap is next lifted up with the lower 
eyelid and eyeball, exposing the floor of the orbit, and the 
infra-orbital canal may be recognized running backward 
and inward ; the canal is opened with a knife or chisel, 
and the nerve separated from the artery and cut oif as far 
back as may be necessary. The nerve may also be reached 
by exposing the anterior wall of the antrum, and trephin- 
ing this and the posterior wall, and, when found, may be 
cut off close to the exit of the main trunk from the round 
foramen in the sphenoid bone. 

Fig. 475. 




A and B. Incisions for resection of supra-orbital nerve. C. Incision for 
resection of the superior maxillary nerve. 



The Inferior Dental Nerve. — To expose this nerve, an 
incision is made along the lower jaw, from a point just 
behind the angle, and carried forward to a point just in 
front of the edge of the masseter muscle ; the periosteum 
and masseter muscle are then separated from the bone 
with an elevator, and the inferior dental canal opened 
with a small trephine or chisel ; the exposed nerve is then 
raised upon a hook and resected. 

The Lingual Nerve. — The lingual nerve may be felt just 
behind the attachment of the pterygo-maxillary ligament, 
on the inner side of the lower jaw, close to the bone, below 
the last molar tooth ; the tongue should be drawn to one 



OPERATIONS UPON NERVES. 



565 



side and the mucous membrane divided for an inch, par- 
allel to the alveolar process, beginning at the last molar 
tooth ; the nerve is then found in the submucous tissue. 

The Facial Nerve. — This nerve may be exposed at the 
posterior border of the ramus of the jaw by an incision 
extending from just in front of the tragus of the ear to the 
angle of the jaw. The parotid fascia is divided, the cervico- 
facial branch is exposed first, and may be followed back 
to its junction with the temporo-facial branch. 

The Brachial Plexus. — The brachial plexus consists of 
the four lower cervical nerves and the greater part of the 



Fig. 476. 




Resection of the brachial plexus. 

first dorsal ; it lies between the anterior and middle scaleni 
muscles and crosses the floor of the subclavian triangle at 
the base of the neck. To expose the brachial plexus, the 
neck and head are extended and the face turned toward 
the opposite side ; an incision is made half an inch above 
the clavicle, between the sterno-cleido-mastoid and trape- 
zius muscles, and carried forward for about three inches 
parallel to the anterior border of the trapezius. The skin 



566 OPERATIONS UPON NERVES. 

and platysma are divided, and the external jugular vein 
is either cut and ligated or held to one side ; the deep 
cervical fascia is next opened in the line of the external 
incision, and the outer border of the anterior scalene 
muscle felt for; the brachial plexus is found just outside 
the latter, and is exposed by careful dissection (Fig. 476). 

The Spinal Accessory Nerve. — To expose the spinal acces- 
sory nerve, an incision about three inches in length is made 
downward from the tip of the mastoid process along the 
anterior border of the sterno-mastoid muscle ; the cervical 
fascia should be divided and the muscle strongly retracted, 
to put the nerve on the stretch. The nerve should be 
found external to the jugular vein, about an inch and a 
half below the tip of the mastoid process, on the fascia 
covering the rectus capitis anticus major. 

The Median Nerve. — The median nerve may be exposed 
at the bend of the elbow or just above the wrist. To 
expose the median nerve at the bend of the elbow, an 
incision is made about an inch and a half in length upon 
the inner edge of the biceps tendon ; the bicipital fascia is 
divided and the nerve exposed at the inner side of the 
brachial artery. The median nerve may also be exposed 
above the wrist by an incision two inches in length along 
the inner border of the tendon of the palmaris longus 
muscle. 

The Ulnar and Radial Nerves. — These nerves may be 
exposed by an incision similar to that employed for liga- 
tion of the ulnar or radial artery. 

The Musculo-spiral Nerve. — The musculo-spiral nerve is 
exposed by an incision on the outer side of the arm above 
the elbow, from the upper part of the supinator groove ; 
the fascia being divided, the nerve is sought for at the 
bottom of this groove. 

The Great Sciatic Nerve. — To expose the great sciatic 
nerve, an incision three or four inches in length is made 
vertically downward from the gluteal fold at a point mid- 
way between the tuberosity of the ischium and the great 
trochanter ; the skin and fascia being divided, the lower 
border of the gluteus maximus and the hamstring muscles 



OPERATIONS UPON TENDONS. 567 

are exposed ; the nerve rests on the external rotators of 
the thigh just in front of the outer side of the hamstring 
muscles. 

The Internal Popliteal Nerve. — This nerve is exposed by 
an incision two inches in length in the middle of the pop- 
liteal space. The nerve is slightly external to the vein 
and artery, and is more superficially placed. 

The External Popliteal Nerve. — This nerve is exposed by 
an incision two inches in length, parallel and close to the 
inner side of the biceps tendon, and lies close behind and 
to the inner side of this tendon. 

The Anterior Crural Nerve. — This nerve is exposed by 
an incision about two inches in length, extending from 
Poupart's ligament downward, and about an inch to the 
outer side of the femoral artery. 



OPERATIONS UPON TENDONS. 

Tenotomy. — This operation consists in the division of 
a tendon, and it may be done subcutaneously or by an 
open operation. The former method of tenotomy is to be 
preferred in most cases, but in certain tendons which lie 
in close proximity to important vessels and nerves it is 
safer to employ the open operation. In dividing tendons, 
the parts should be placed in such a position as to render 

Fig. 477. 



Sharp-pointed tenotome. 

the tendons tense. The instruments required are a sharp- 
and a blunt-pointed tenotome. The sharp-pointed ten- 
otome (Fig. 477) is used to make a puncture down to the 
edge of the tendon, being entered flatwise ; it is then with- 
drawn and a blunt-pointed tenotome (Fig. 478) introduced 
through the puncture, passed under the tendon, and turned 
so that the tendon rests upon its cutting edge; by a gentle 



568 



OPERATIONS UPON TENDONS. 



rocking motion the tendon is then divided, and the ten- 
otome turned flatwise and withdrawn. 




Blunt -pointed tenotomes. 

The Tendo-Achillis. — In dividing this tendon, a sharp- 
pointed tenotome should be entered at the inner border 
of the tendon about an inch above its attachment to the 
calcaneum (Fig. 479); the heel should be depressed as 

Fig. 479. 




Tenotomy of tendo-Achillis. 

much as possible, so as to make the tendon prominent, and 
a sharp-pointed tenotome passed through the skin and 
behind the tendon ; it is next withdrawn and a blunt- 
pointed tenotome introduced and the tendon divided. The 
posterior tibial artery, nerve, and vein lie to the inner side, 
and are not likely to be injured if the tendon is divided 
at this point. 

The Posterior Tibial Tendon. — This tendon may be 
divided above the inner malleolus. The muscle is made 
tense by everting the foot, and the tenotome is entered at 
the inner side of the tendon and passed behind it. The 
posterior tibial tendon may also be divided upon the side 
of the foot ; for this operation the foot is everted, and the 
tenotome is passed from above downward and under the 



OPERATIONS UPON TENDONS. 569 

upper border of the tendon at a point half an inch below 
and in front of the tip of the internal malleolus. To avoid 
injury of the posterior tibial artery and nerve the open 
operation is generally practised upon this tendon. 

The Anterior Tibial Tendon. — This tendon is divided 
upon the dorsal surface of the foot, just below the an- 
nular ligament of the ankle, midway between the two 
malleoli. 

The Peroneal Tendons. — The peroneal tendons may be 
divided about an inch above the external malleolus, the 
tenotome being passed from before backward between the 
fibula and the tendons, or the tendons may be divided at 
a point midway between the end of the external malleolus 
and the tubercle of the cuboid. 

The Hamstring Tendons. — The inner hamstring consists 
of the tendons of the semi-tendinosus, semi-mem branosus, 
gracilis, and sartorius. The external hamstring consists 
of the tendon of the biceps. To divide either of these 
tendons, the knife is entered at the inner side of the 
tendon. In dividing the external hamstring, care should 
be taken to keep close to the tendon of the biceps, as the 
external popliteal nerve lies close to its inner border. 
For this reason the open operation is advisable upon this 
tendon. 

The Adductor Longus. — To divide this tendon, abduct 
the thigh and make the muscle prominent near its inser- 
tion ; then pass the tenotome from without downward and 
inward. 

The Flexor Longus Pollicis. — This tendon may be divided 
on the first phalanx or near the inner edge of the foot, 
where it may be made prominent by strong extension of 
the great toe, the tenotome being passed close to the border 
of the tendon. 

The Extensor Longus Digitorum. — These tendons are 
divided upon the dorsal surface of the metatarsal bones, 
where they are quite prominent. They may also be 
divided near the ankle. 

The Extensor Proprius Pollicis. — This tendon may be 
divided in the same incision used for division of the long 



570 



OPERATIONS UPON TENDONS. 



extensor of the toes, the point of the knife being carried 
inward. 

The Sterno-cleido-mastoid Muscle. — In tenotomy of this 
muscle, the sternal and clavicular attachments are divided 
about an inch above the sternum and clavicle. A puncture 
is made to the outer side of the muscle with a sharp teno- 
tome, and when the tendinous expansion of the muscle is 
reached it is withdrawn, a blunt tenotome substituted, and 
the structure divided (Fig. 480). The sternal attachment is in 
like manner divided through a separate puncture. The exter- 
nal jugular vein at the outer border of the muscle is to be 
avoided. The division of the muscle, or its tendinous 
expansion by an open operation, is now often practised, as 
there is less risk of injuring the vein by this procedure. 

Fig. 480. 




Tenotomy of sterno-mastoid. 



Suture of Tendons. — In bringing together the divided 
ends of tendons, primary or secondary sutures are em- 
ployed ; primary sutures are those introduced immediately 
after the injury, and secondary sutures are those intro- 
duced after retraction of the ends has occurred and the 
wound has healed. 

Primary Suture of Tendons. — The material employed for 



SUTURE OF TENDONS. 



571 



sutures may be silk, silkworm-gut, catgut, or kangaroo- 
tendon, and one or more sutures should be used, being 
passed through the substance of the ends of the tendon 
and secured by tying ; the divided sheath of the tendon, 
if possible, should be brought together by fine silk sutures 
(Fig. 481). Very marked retraction of the ends of the 
tendon is liable to occur, and a considerable dissection is 
often required to bring them into view. 

Fig. 481. 




Suture passed through the substance of the ends of a divided tendon. 

When there is difficulty in bringing the ends of the 
tendon together, and the sutures are apt to cut out, the 
form of suture shown in Fig. 482 may be employed. 

Fig. 482. 




Tendon-suture which does not easily tear out. (Stimson.) 



Secondary Suture of Tendons. — In applying secondary 
sutures to tendons, the principal difficulty is often encount- 
ered in bringing the ends of the tendon in contact and in 
holding them successfully in this position. The ends of 
the tendon have first to be freshened, and this may be done 
by cutting them obliquely and introducing a suture as 



572 



OPERATIOSS UPON TENDONS. 



shown in Fig. 483. This method of section presents a 
large raw surface of the tendon for union. 

Lengthening of Tendons. — When so large a gap exists 
between the ends of the tendon that they cannot be brought 



Fig. 483. 




Oblique section of ends of tendon to increase surface of contact. (Stmsox.) 

into apposition, a plastic operation may be performed upon 
their ends, which often overcomes the difficulty. This 
consists in making a section halfway through the tendons, 
at some distance from their ends, and splitting them toward 
their divided extremities, and then turning out these flaps 
and securing their ends by means of sutures (Fig. 484). 



Fig. 484. 




Lengthening of retracted tendon by flaps. (Stimson.) 



When the ends of the tendon are so widely separated that 
they cannot be approximated, sutures a distance may be 
employed. These consist of sutures of sterilized silk or 
chromicized catgut passed between the ends of the tendon 
and tied, the sutures acting as a scaffolding upon which 



EXCISION OF THE MAMMARY GLAND. 573 

reparative material forms between the separated ends of 
the tendon. 

Transplantation of Tendons. — This operation consists 
in altering the attachments of the tendons of healthy 
muscles so as to have them fulfil the functions of those 
which are paralyzed. Four methods of transplantation 
are practised : first, the tendon of the healthy muscle may 
be completely divided and the upper end sutured to the 
paralyzed tendon ; second, the tendon of the paralyzed 
muscle may be divided and the lower end sutured to the 
healthy one : third, the tendon of the sound muscle may 
be split, one end remaining attached to its normal insertion, 
and the other sutured to the paralyzed tendon ; fourth, 
a portion or the whole of the healthy tendon may be 
implanted subperiosteal ly at the desired point, instead of 
stitching it to the paralyzed tendon. 



ORDINARY EXCISION OF THE MAMMARY GLAND. 

The region of the neck, shoulder, upper arm, breast, and 
side-wall of the chest should be rendered aseptic by the 
usual preparation, the axilla being thoroughly shaved. The 
arm should be held at a right angle with the body. 

An elliptical incision should be made, with its long axis 
parallel with the anterior axillary fold, its centre corre- 
sponding with the nipple. The incision is continued into 
the axilla, over the upper point of the ellipse, and one 
also made extending a short distance below its lower por- 
tion. The skin and superficial and connective tissue are 
then divided, bleeding vessels being clamped with haemo- 
static forceps, and the fibres of the pectoral muscle are ex- 
posed. Drawing the breast away from the thoracic wall, the 
surgeon frees it from the pectoralis major muscle. The 
breast is then drawn upward, and the surgeon divides the 
tissues down to the thoracic muscles along the low r er line of 
the ellipse. The connective tissue of the breast is now sev- 
ered towards its axillary aspect, and the breast is freed from 
the chest. If it is desired to explore the axilla, the in- 
cision is carried further upward,, and enlarged glands are 



574 OPERATION FOR REMOVAL OF BREAST. 

felt for and removed. After hemorrhage has been con- 
trolled, the edges of the wound are brought together with 
silkworm-gut sutures. A drainage-tube may be introduced 
if it is considered desirable. 



OPERATOIN FOR RADICAL REMOVAL OF THE 
BREAST. 

The arm should be held at a right angle to the body 
and an incision made over the insertion of the pectoralis 
major muscle into the humerus, over the point of the 
shoulder, and then downward on the chest-wall to the 
inner side of the nipple to a point two or three inches be- 
low the lower margin of the gland. From the upper 
portion of this incision a second incision is carried down- 
ward along the edge of the pectoral muscle, and curved 
inward, to meet the lower extremity of the first incision. 
These incisions are carried through the skin and superficial 
fascia, which are dissected, so as to expose the pectoral 
muscle throughout its entire length. The tendon of the 
muscle is next separated from its attachment to the hu- 
merus and retracted downwards, and the attachment of 
the pectoralis minor muscle exposed and severed ; the cla- 
vicular fibres of the pectoralis major may be left. The 
axillary space is now exposed, which is next cleared, from 
above downward, of all fascia, lymphatics, and connective 
tissue, care being taken to preserve, if possible, at the lower 
portion, the subscapular and posterior thoracic nerves. 
After clearing the axillary space, the costal and sternal at- 
tachments of the pectoralis major muscle are divided, as 
well as those of the pectoralis minor. The entire mass, 
consisting of the mammary gland, both muscles, the axil- 
lary glands, and the connective tissue, is then removed. 
If it is desired to remove the connective tissue and glands 
from the supraclavicular space, a curved or straight inci- 
sion several inches in length is made above the clavicle, 
and the lymphatics and connective tissue along the sub- 
clavian vessels and behind the sterno-mastoid muscle are 
removed. Before bringing together the edges of the 



TRACHEOTOMY. 575 

wound a small opening is usually made for drainage through 
the axillary flap, and a cigarette drain or rubber drainage- 
tube introduced. The incisions are then brought together 
with silkworm-gut sutures, and a large gauze dressing is 
applied over the entire wound, and the arm is secured to 
the side of the chest by circular turns of a bandage. 

TRACHEOTOMY. 

This operation consists in dividing the tissues over the 
trachea in the median line of the neck, and after the trachea 
has been exposed it is opened by dividing two or three of 
the tracheal rings. 

Under certain circumstances the operation may be per- 
formed with very few instruments ; but if the surgeon has 
the choice, he will find it convenient to have at hand two 
small scalpels, one short grooved director, a tenaculum, 
two aneurism needles (which may be used as retractors), 
one pair of artery forceps, haemostatic forceps, two pairs 
of dissecting-forceps, a pair of scissors, a sharp-pointed 
tenotome, a pair of tracheal forceps, a tracheal dilator, 
tracheotomy tubes, tapes, ligatures, sponges, a flexible 
catheter, and feathers. The director should be short ; the 
ordinary grooved director is too long to use with satisfac- 
tion in operating upon the short necks of children ; so 
that I use a shorter and somewhat broader one, having a 
bevelled extremity, which allows it to be passed with ease 
between the different layers of the tissues (Fig. 485). 

' Fig. 485. 




Author's tracheotomy director. 



Haemostatic forceps are also useful in controlling hem- 
orrhage during the operation in case of the division of 



576 



TRACHEOTOMY. 



vessels which bleed freely, when the operator from the 
urgency of the case does not think it justifiable to ligate 
them at the time of their division. They may also be 
employed under similar circumstances to clamp the isth- 
mus of the thyroid gland on either side of the trachea 
when it becomes necessary to divide it to expose the 
trachea. 

A sharp-pointed tenotome is the instrument I prefer to 
employ in opening the trachea, as its sharp point enables 
it to be easily thrust into the trachea. 

Tracheal dilators of various kinds are employed, but 
the most satisfactory tracheal dilator which I have em- 
ployed is that of Golding-Bird (Fig. 486), which is a 
self-retaining instrument; the blades are slipped through 
the tracheal incision and are then expanded by turning 
the screw to which they are attached. Trousseau's tracheal 
dilator, the blades of which are introduced through the 
incision in the trachea and are expanded by bringing 
together the handles, is also a satisfactory instrument (Fig. 
487), but it is not so useful as Golding-Bird's dilator, as 
it has to be retained in position by the hand. Tracheal 
dilators may be improvised from bent hair-pins or pieces 
of wire, which will often serve a useful purpose where 
ordinary dilators cannot be obtained. 






Fig. 486. 



Fig. 487. 





Golding-Bird's tracheal dilator. 



Trousseau's tracheal dilator. 



It is also well to have at hand a number of pliable 
feathers, to be used in clearing the trachea or larynx of 
mucus or membrane after it has been opened ; by their use 



TRACHEOTOMY. 



577 



this object may be accomplished with little risk of injury 
to the mucous membrane. 

Fig. 488. 




Tracheal forceps. 

Tracheal forceps, which are constructed with a double 
spring and curved blades, are also useful in removing 
membrane or foreign bodies from the larynx above the 
wound or from the trachea below the tracheal incision 
(Fig. 488). 

Tracheotomy-tubes of various shapes are made of silver, 



Fig. 489. 





Silver tracheotomy-tube. 



Silver tracheotomy -tube -with 
fenestrated guide. 



aluminum, hard and soft rubber, but the tube which I 
consider the most satisfactory for general use is a silver 
quarter-circle tube with a movable collar (Fig. 489), and 
provided with a fenestrated guide (Fig. 490). A satisfactory 

37 



578 



TRACHEOTOMY. 



tracheotomy-tube is one which inflicts the least possible 
injury upon the mucous membrane of the trachea, and to 
insure this object the part of the tube within the trachea 
should lie exactly in its axis, and its free extremity should 
be capable of as little movement as possible. The trache- 
otomy-tube is held in position, after being introduced, by 
means of tapes attached to the shield of the tube and tied 
around the neck. 

Position of Patient for Tracheotomy. — The best posi- 
tion in which to place the patient for this operation is one 
which brings the neck into the greatest prominence, and 
this may best be obtained by laying the patient upon his 
back upon a firm table and placing under the shoulders a 
round cushion; or an empty wine-bottle or a roller-pin 
wrapped in towels, will answer the same purpose (Fig. 
491); or the head may be held over the edge of the table. 
If an anaesthetic is not used, the arms should be held by 
an assistant, which is better than securing them by a 
binder around the chest, which restricts respiratory move- 
ments. 

Fig. 491. 




Position of patient for tracheotomy. 



Operation of Tracheotomy. — The trachea may be 
opened above the isthmus of the thyroid gland or below 
it, and these operations constitute respectively the high 
and the low operation. 



OPERATION OF TRACHEOTOMY. 579 

The high operation is generally selected, because at this 
point the trachea is more superficial and is more easily 
exposed, whereas in the low operation the trachea is more 
difficult to expose by reason of its relatively greater depth, 
the large size and number of veins, and its proximity to 
the large arterial trunks. 

High Operation. — The patient being placed in position, 
the operator stands at the head of the patient; this posi- 
tion I prefer, as it is easier from this point to keep the 
incisions exactly in the median line of the neck. The 
operator next makes himself familiar with the landmarks 
of the neck; locating the position of the cricoid cartilage, 
he makes an incision through the skin in the median line 
of the neck from one and a half to two inches in length, 
the position of the cricoid cartilage being the middle point. 
There is no disadvantage in making a longer incision if a 
freer exposure of the parts is required. Having divided 
the skin, the operator will often see a large vein lying in 
the superficial fascia — the superficial anterior jugular ; 
this should be displaced and the fascia divided upon a 
director. 

The surgeon should keep his incisions strictly in the 
median line of the neck, for this is the line of safety ; and 
he should be careful, as the wound increases in depth, not 
to make the incisions too short, so that the wound becomes 
funnel-shaped. AVhen the deep fascia is exposed, it should 
be picked up and divided upou a director ; any large veins 
in the line of the wound should be carefully displaced, or, 
if this is impossible, they should be ligated on each side 
and then divided between the ligatures. 

The operator next looks for the intermuscular space 
between the stemo-hyoid and the ster no-thyroid muscles, 
which may generally be found without difficulty ; the mus- 
cles are now separated in this line, with the handle of the 
knife or with a director, and the isthmus of the thyroid 
gland exposed. The muscles should now be held aside 
by retractors placed on either side. He should carefully 
explore the wound with the finger, to locate exactly the 
position of the trachea, and to ascertain, if possible, the 
presence of anomalous arteries. 



580 TRACHEOTOMY. 

The isthmus of the thyroid gland having been exposed, 
which generally occupies a position over the first three 
tracheal rings, the gland will be found surrounded by a 
plexus of veins, which should be displaced with the direc- 
tor ; or, if this is impossible, they should be ligated on 
each side and divided between the ligatures. The thyroid 
isthmus is next displaced upward or downward, according 
as the surgeon desires to open the trachea below or above 
this body. This is often done without difficulty, especially 
its upward displacement; but when there is difficulty in 
displacing it downward, a procedure recommended by 
Bose may be employed, which consists in making a trans- 
verse incision across the cricoid cartilage to divide the 
layer of fascia by which the isthmus is bound down; the 
director is then passed into this incision and the isthmus 
is depressed without difficulty. 

Having displaced the isthmus of the thyroid gland 
downward, the trachea, yellowish white in appearance, 
covered by the tracheal fascia, will be exposed ; this fascia 
should next be thoroughly broken up with a director or the 
handle of the knife, so as to bare the trachea, and in doing 
this the operator may feel it crepitate under the finger from 
the suction of air drawn in with inspiration. The trachea 
is next fixed with a tenaculum, introduced into it a little 
to one side of the median line; an incision is made into 
it with a narrow knife from below upward, from one- 
half to three-fourths of an inch in length (Fig. 492), care 
being taken to see that this incision is in the median line, 
for if the trachea be opened by a lateral incision the 
wound does not heal so promptly and the tracheotomy- 
tube does not fit well, and its lower extremity may cause 
injury to the mucous membrane of the trachea. If the 
wound be a deep one, after fixing the trachea with the 
tenaculum the operator may lift it slightly from its bed, 
thereby bringing it more prominently into view and mak- 
ing it more superficial in the wound, thus facilitating its 
opening. As soon as the incision is made into the trachea, 
air mixed with blood and mucus escapes from the incision. 
A tracheal dilator should next be introduced and the 






LABYNGOTOMY. 



581 



trachea cleared of membrane, if it is present in the region 
of the wound, with a feather or with forceps. The tra- 
cheotomy-tube is next introduced, and is secured in position 
by tapes tied around the neck. If respiration has ceased, 
artificial inspiration should be resorted to. 



-■: 




- 1 

Opening of the trachea . Lxstoh. 

Laryngotomy. — In this operation an opening is made 
into the air-passages through the crico-thyroid membrane. 

It is a -i tuple operation, and one which is practically free 
from risk, and can. therefore, be performed moch more 
rapidly and safely in urgent cases than tracheotomy. 

The patient being placed in the recumbent posture, with 
the shoulders slightly elevated and the head thrown back. 
to make the neck as prominent as possible, the sui 
feels for the prominence of the thyroid cartilage, and 
stead viD^r the larynx between the finger and thumb of the 
left hand, lie makes an incision in the median line over 
the centre 01 the thyroid cartilage and extending down- 
ward for an inch or an inch and a half. The skin and 
supt-rficial fascia bein^ divided, the fascia between the 
: seles and the areolar tissue is exposed and 
divided, and the - rid tut braneis exposed. The 



582 INTJJBATION OF THE LARYNX. 

knife is then passed transversely through the membrane into 
the larynx, care being taken that both that membrane and the 
mucous membrane which covers its inner surface are divided 
at the same time. As soon as the knife enters the cavity of 
the larynx blood and mucus will be forcibly expelled. 

The wound should be carefullv enlarged and a tube 
introduced, which differs from the ordinary tracheotomy- 
tube in being slightly flattened ; this is secured in position 
by tapes tied around the neck, as in the case of the ordi- 
nary tracheal tube. The only bleeding which is likely to 
occur is from the crico-thyroid arteries or veins, and if these 
cannot be avoided, and are divided in the operation, they 
should be temporarily secured by haemostatic forceps or li- 
gated ; if the case is not extremely urgent, all bleeding should 
be arrested before the crico-thyroid membrane is incised. 

Laryngo- tracheotomy.— This operation consists in 
making an incision into the air-passages by dividing one 
or two of the upper rings of the trachea, the crico-tracheal 
membrane, the cricoid cartilage, and the crico-thyroid 
membrane. This operation is employed in cases where, 
from the age of the patient, the crico-thyroid space is too 
small to admit of a sufficient opening, or in those in which, 
for any reason, the surgeon does not deem it advisable to 
attempt to open the trachea lower down. The incision in 
the skin and superficial fascia of the neck is made in the 
same manner as in the operation of laryngotomy, but is 
carried a little further downward. It may be necessary 
to displace the isthmus of the thyroid gland downward to 
expose the upper portion of the trachea, and when the 
trachea is exposed the incision should be made through 
this and the cricoid cartilage from below upward. A 
tracheotomv-tube is introduced through the wound and 
secured by tapes tied around the neck. 

INTUBATION OF THE LARYNX. 

This procedure, at the present time, is widely employed 
as a substitute for tracheotomy in the treatment of dyspncea 
due to inflammatory affections of the larynx or trachea, or 



INTUBATION OF THE LARYNX. 583 

stenosis of the larynx ; it consists in the introduction of a 
metallic or hard-rubber tube into the larynx, which is 
allowed to remain in place for a few days. This oper- 
ation has been reintroduced to the profession by the late 
Dr. O'Dwyer, of New York, who devised a set of in- 
genious instruments for the purpose of laryngeal intu- 
bation. 

The instruments required are a mouth-gag (Fig. 493), 

Fig. 493. 




Mouth-gag. 
Fig. 494. 



Intubation-tube and introducer. 



with which the jaws are separated and held open ; an in- 
strument for the introduction of the tube, which is fastened 



584 



INTUBATION OF THE LARYNX. 
Fig. 495. 




Fig. 496. 



fi-12- 



5-7 — 



3—*- 



Intubation-tube extractor. 

to the obturator, which fills the cavity of the tube (Fig. 
494); and an instrument for extracting the 
tube after it has been placed in the larynx 
(Fig. 495). The tubes are of metal or hard 
rubber, and have a collar which rests upon 
the false cords, and bulge slightly toward their 
middle and again taper toward their lower 
extremity ; at the collar of the tube there is a 
perforation through which a strand of silk is 
passed which is made into a loop ; this is used 
to enable the operator to remove the tube if 
on its introduction it is found to have passed 
into the oesophagus instead of the larynx, 
and is also useful in removing the tube if it 
becomes occluded with membrane while in the 
larynx. The intubation set now in common 
use is provided with a scale of seven tubes, 
ranging in size from such as are suited for a 
child of one year or less up to the age of 
twelve or fourteen years (Fig. 496). Special 
tubes are required for intubation in adults. 

Operation of Intubation of the Larynx. — In perform- 
ing the operation of intubation, the child is placed upon 
the lap of the nurse or assistant, wrapped in a blanket, 
and the arms secured by the nurse holding the elbows 
so as not to interfere with the respiratory movements. 
The patient's head is next held by an assistant. The 
position of the head, neck, and body should be as if the 
child were hung from the top of the head, and this posi- 
tion should be maintained during the insertion of the 



Scale of intuba 
tion-tubes. 



INTUBATION OF THE LARYNX. 



585 



tube. The mouth-gag is next inserted upon the left side, 
and the blades dilated so as to open the jaws widely, and 
as the gag is self-retaining, this position is easily main- 
tained. The jaws being thus held open, the operator, 
sitting on a chair facing the patient (Fig. 497), next intro- 
duces the index finger of the left hand, protected by a 
strip of adhesive plaster or a metal shield, into the mouth 
and passes it over the tongue until he feels the epiglottis. 
The introducing-instrument, to which the tube is attached, 




Intubation ot the larynx. 



is held in the right hand, and introduced into the mouth, 
after observing that the silken loop is free ; it is swept 
over the tongue and passed down until it touches the epi- 
glottis; this is hooked up by the index finger of the left 






586 INTUBATION OF THE LARYNX. 

hand and the tube passed into the larynx; the index 
finger of the left hand is then transferred to the edge of the 
tube, and by pressing upon the trigger of the instrument 
with the thumb of the right hand the obturator is detached 
and the instrument is withdrawn, and before removing the 
finger it is well to place it upon the head of the tube and 
to sink it well into the larynx. As soon as the obturator 
is removed, there is usually a violent expiratory effort, 
which is accompanied by a gush of mucus, mucopurulent 
matter, or membrane from the tube, and after this escapes 
the breathing is usually satisfactorily established. If the 
operator has passed the tube into the oesophagus and has 
detached it from the introducing-instrument, no improve- 
ment in the respiration takes place ; it should then be 
withdrawn by the silk loop attached to the tube, and another 
attempt made to introduce it into the larynx. 

The mistake, which inexperienced operators make in 
attempting to introduce the tube is in not hugging the 
posterior surface of the tongue closely, thereby passing 
the tube over the epiglottis into the oesophagus. 

The silken loop may be brought out at one side of the 
mouth and adjusted around the ear or fastened to the 
side of the face by strips of adhesive plaster for a few 
hours, so that by drawing upon it the nurse or attendant 
can withdraw the tube instantly if it should become 
obstructed with membrane ; or, if it is coughed up, by 
this means it may be withdrawn from the oesophagus if 
it has not been expelled from the mouth. Some operators 
keep the loop attached to the tube during the time it is 
retained in the larynx. I prefer to remove it after the 
tube is securely placed in the larynx, and to withdraw the 
tube by means of the extracting-instrument when required. 
The tube should be removed at the end of the second or 
third day, and if the child can breathe comfortably for an 
hour or two it need not be reintroduced; if, however, the 
dyspnoea returns, it should be reintroduced, and allowed to 
remain one or two days longer ; several attempts may have 
to be made before the tube can be permanently removed ; it 
is usually dispensed with from the third to the eighth day. 



INTUBATION OF THE LARYNX. 



587 



The most serious complication Avhich is apt to occur 
during the introduction of the intubation-tube is the 
detachment and pushing of a mass of membrane in front 
of the tube into the trachea ; if the mass is too large to 
be expelled through the tube, the breathing is suddenly 
arrested. The tube should be removed at once, and if the 
mass of membrane does not escape with the expiratory 
efforts of the patient, the trachea should be rapidly opened 
as the only means of re-establishing the respiratory func- 



Fig. 498. 




Feeding a ease of intubation of the larynx 



tion. So much do I dread this accident, which has 
occurred in a few cases, that I never introduce the intuba- 
tion-tube without having at hand the necessary instru- 
ments to do a tracheotomy if it should be suddenly 



588 OPEEATIONS UPON THE KIDNEY. 

required, and, if possible, obtain the consent of the parents 
or friends to perform tracheotomy if it should be indicated. 
Feeding after Intubation. — One of the greatest difficul- 
ties after intubation of the larynx is the satisfactory feed- 
ing of the patient ; liquids, as a rule, are not swallowed 
well, a portion escaping into the tube, causing coughing 
and difficulty in breathing. The diet I usually prefer is 
semisolid, such as corn-starch, soft-boiled eggs, and mush ; 
and if these are not well swallowed, it may be necessary 
to resort to nutritious enemata or the use of a stomach- 
tube to introduce food. Some patients swallow liquids and 
semisolids quite well if the head is placed a little lower 
than the body during the act of deglutition (Fig. 498). 



OPERATIONS UPON THE KIDNEY. 

Nephrotomy. — In this operation an incision is made 
into the kidney. The incision for exposure of the kidney 
is four inches in length, and should be made from a point 
two and a half inches from the spine, half an inch below 
the last rib and parallel with it. The latissimus dorsi, 
external and internal oblique, and transversalis muscles 
are divided, and the lumbar fascia is opened, exposing the 
perinephric fat ; the kidney is then reached by displacing 
this. 

Lumbar Nephrectomy. — The incision is the same as 
for nephrotomy ; the wound may be enlarged by another 
incision at right angles to the first if more space is required. 
After the kidney is exposed, its capsule is incised and the 
finger passed around the organ to separate it freely from 
the capsule. When the ureter is recognized, it is brought 
into view, ligated, and cut off. The pedicle containing 
the vessels is next tied, and divided in advance of the lig- 
ature with scissors, and the kidney removed. 

Abdominal Nephrectomy. — To reach the kidney by 
abdominal incision, an incision four inches long is made 
at the outer border of the rectus muscle ; the abdomen 
is opened and the viscera turned aside; the kidney is 






OPERATIONS UPON THE URETER. 589 

exposed and the capsule opened ; the ureter and the renal 
vessels are ligated and divided, and the organ removed ; 
a drainage-tube may be introduced or the wound in the 
abdominal walls may be closed without drainage. 

Nephrorrhaphy or Nephropexy. — Xephrorrhaphy is 
an operation in which the kidney is exposed through a 
similar incision to that for nephrotomy, with the object of 
suturing a movable kidney fast in its normal position 
in the back ; when the kidney has been reached, a number 
of sutures are introduced into the capsule of the kidney 
and secured to the fibrous and muscular tissue of the in- 
cision. Many surgeons prefer to omit the introduction of 
sutures, and simply scarify the capsule of the kidney or 
dissect off a portion of the capsule, and then pack the 
wound with strips of gauze and allow it to heal by granu- 
lation. 

Other methods of fixing a movable kidney consist in 
dissecting a flap from the capsule of the kidney and sutur- 
ing it to the muscular tissues of the external wound before 
closing the wound. Some surgeons prefer to introduce no 
sutures, but to pass two gauze loops around the kidney at 
different points, and pack the wound with gauze. The 
loops are not removed for a few days, and the wound is 
allowed to heal by granulation. 

OPERATIONS UPON THE URETER. 

Ureterotomy. — This operation consists in the exposure 
of the ureter by an oblique lumbar incision, and its incision 
for the removal of a calculus. The pelvic portion of the 
ureter mav be exposed by an extension downwards of the 
oblique lumbar incision to the iliac region, and retraction 
of the peritoneum from the ilio-psoas muscle and side-wall 
of the pelvis. In the female the pelvic portion of the ure- 
ter may be exposed by the extraperitoneal route or by 
vaginal incision. 

Ureterectomy. — This consists in exposing and resecting 
a portion of the ureter, and the operation may be required 
for stricture or growths of the urethra. When the ureter 



590 



OPERATIONS UPON THE URETER. 



is resected, the resected ends of the ureter should be united 
or the free end should be implanted into the bladder. 

Uretero-ureterostomy. — This consists in uniting the 
ends of a divided ureter to secure patency of the canal. 
The lower segment of the ureter is ligated with silk, and 
longitudinal incision is made into the ureter just below the 

Fig. 499. 





Uretero-ureteral anastomosis, end-in-side implantation (Van Hook's method) : 
a, first step ; b, second step ; c, completed operation. (Beyant.) 



ligature. A loop of catgut threaded with double needles is 
passed through the tip of the upper end of the ureter, and 
this is drawn through the incision by means of the catgut 
loop, the needles passing out of the ureter a little below the 
lower limit of the incision ; the catgut ligature is then tied 
and a few additional sutures are applied (Fig. 499). 



OPERATIONS UPON THE COLON. 591 

IMPLANTATION OF URETER INTO BLADDER. 

When the distal end of the ureter is too short to admit 
of an anastomosis the urethra may be implanted into the 
bladder. The distal portion of the ureter should be ligated 
and an incision made into the bladder near the ureteral ori- 
fice. The upper end of the ureter is drawn down by a loop 
of catgut as in the method of Van Hook and is secured 
by tying the ends a little below the wound. A few inter- 
rupted sutures of catgut or fine silk are next introduced 
at the line of union. Additional security may be obtained 
by suturing over the wound a layer of peritoneum or 
omentum. 

OPERATIONS UPON THE COLON. 

Lumbar Colostomy. — In performing lumbar colotomy, 
or colostomy, on the left side, the patient should be placed 

Fig. 500. 



Incision in lumbar colostomy— dotted line shows the situation of the colon. 
(Bryant.) 

upon the right side, and a pillow placed under the loin to 
make the left side more prominent. An incision four 
inches in length is made midway between the last rib and 
the crest of the ilium, the centre of the incision corre- 
sponding to a point midway between the anterior superior 



592 



OPERATIONS UPON THE COLON. 



and posterior superior spines of the ilium ; the tissues are 
divided to the full extent of the wound until the lumbar 
fascia and edge of the quadratus lumborum muscle have 
been reached ; the former being cut through and the edge 
of the muscle divided, the bowel is exposed, when it is 
brought to the surface and fastened by sutures to the skin 
and subjacent tissues, and opened (Fig. 500). 

Inguinal Colostomy. — In this operation an incision 
three inches in length is made on the left side parallel to 
and one inch above Poupart's ligament, with its centre on 
a level with the anterior superior spine of the ilium, or a 
little lower; or, as practised by Ball, the colon may be 
exposed by an incision two and a half inches in length, 
following the line of the linea semilunaris, stopping just 
short of Poupart's ligament ; the tissues are divided layer 
by layer and the peritoneum opened ; the skin and parietal 
peritoneum may be united by a few sutures ; the gut is 
then brought out at the wound, fastened to its margins by 
fine sutures, and opened. 

Maydl's Operation. — In this operation the colon is 
exposed as in the preceding operation, and then drawn out 



Fig. 501. 




Colon held in wound by glass rod. (Pilcher.) 

of the wound until its mesenteric attachment is on a level 
with the external incision. A sterilized glass rod or piece 
of catheter, or a roll of gauze three inches in lengthy is 
slipped through a slit in the mesocolon close to the gut (Fig. 
501). This holds the intestine in the wound and prevents 



PEE ATIOS FOE ACUTE APPESDICITIS. 



593 



it- return to the abdominal cavity until adhesiuns have 
formed. The two limb- of the flexure of the gut ex: 
in the wonnd should be united by suture- eneath the 
rod. If the trut is to be opened immediately, it should 
be stitched to the parietal peritoneum of the abdominal 
incision. If the opening of the bowel can be post 1 
for twenty-four or forty-eight hours, the introduction of 
sutures is not required. The bowel may be opened by a 
transverse incision with a knife, or by the thermo-cautery. 
to avoid bleeding. 



OPERATION FOR ACUTE APPENDICITIS. 

An incision three inches in length should be made over 
the outer portion of the rectus muscle about half an inch 

from its external border. The skin and connective tissue 



I 




Method of burying the stump of the appendix. 



;.::K^r 



are divided, and the sheath is exposed and opened in the 
direction of the cutaneous incision,and the muscular fibres 
are retracted inward. This incision exposes the post 

0? 



594 OPERATION FOB ACUTE APPENDICITIS. 

wall of the sheath, and the epigastric vessels, which may 
be retracted or divided. The posterior layer of the sheath 
of the rectus is then opened, exposing the peritoneum and 
subconnective tissue, which is grasped with two pairs of 
forceps, carefully drawn up and divided. 

If a tumor exists in the right iliac fossa, indicating an 
inflammatory exudate or appendicular abscess, the incision 
should be made over the most prominent portion of the 
mass. 

After exposing the peritoneal cavity, if no abscess is pres- 
ent, the finger is introduced and the appendix sought for, or 
the wound may be dilated with retractors, and the search for 
the appendix aided by inspection of the parts. If the appen- 
dix is freely movable, it may be drawn through the wound, 
the meso-appendix ligated in two or three portions, and the 
base of the appendix securely ligated with a catgut or silk 
ligature, and the appendix divided in advance of the liga- 
ture. The cut surface of the appendix should then be 
touched with a drop of pure carbolic acid or the actual 
cautery. If, however, the appendix is bound down by 
adhesions, these should be carefully separated and the 
meso-appendix ligated, and after the base of the appendix 
has been tied off, it should be removed as described above. 
After removing the appendix in such a case, a cigarette 
drain or a rubber tube should be introduced, and the 
wound of the abdominal walls should be partially closed 
with layer sutures, one set closing the peritoneum, a second 
the muscular fibres, a third the fascia, and another the skin 
and connective tissue. 

If, on opening the abdomen, inflammatory exudate is 
found, strips of sterilized gauze packing shoidd be intro- 
duced to shut off the adherent intestines from the general 
peritoneal cavity, and by introducing the finger the struc- 
tures around the appendix are gently separated in their lines 
of natural cleavage. As soon as pus escapes, the opening 
should be enlarged and the pus gently wiped away with pads 
or sponges, and the wound dilated so as to expose the appen- 
dix as freely as possible. When the appendix is found it 
should be removed. A cigarette drain or rubber tube 



OPERATION FOR CHRONIC APPENDICITIS. 595 

should be introduced into the cavity , and it should also be 
loosely packed with gauze. The gauze packing may be 
then taken out and replaced with clean packing, and the 
wound should be partially closed by sutures or layer su- 
tures. If there is free fluid in the peritoneal cavity in 
addition to the localized abscess, or if the abscess ruptures 
and pus escapes into the pelvis, this should be cleansed by 
sponges or by irrigation with warm salt solution or sterile 
water, thoroughly dried with gauze pads, and drainage- 
tubes or cigarette drains introduced and carried down to 
the bottom of Douglass's pouch. If, on opening the peri- 
toneal cavity, it is found that there is a diffused peritonitis, 
the entire peritoneal cavity should be flushed with an 
abundance of hot sterile water or salt solution, rubber, 
cigarette, or gauze drains should be introduced, and the 
wound partially closed and dressed. 

OPERATION FOR CHRONIC APPENDICITIS. 

In removing the appendix in the interval between 
attacks, two methods may be employed — either McBurney's 
method or by an incision through the outer edge of the 
rectus muscle. 

McBurney's Operation. — This consists in making an 
incision two or three inches in length parallel with the 
fibres of the external oblique aponeurosis, the centre of 
which would lie a little to the outer side of McBurney's 
point. The skin and subcutaneous tissues are then divided 
down to the aponeurosis, the latter is then split in the 
direction of its fibres and well retracted, exposing the in- 
ternal oblique, the fibres of which are next separated by 
a blunt dissection and retracted in the opposite direction. 
The transversalis fibres are then separated in the same 
manner, which exposes the transversalis fascia and sub- 
peritoneal fat. These structures are next divided, and the 
peritoneum drawn upward in the transverse fold by two 
pairs of haemostatic forceps and opened. The wound is 
next carefully enlarged, and the colon is usually found 
directly beneath the opening, and may be recognized by 



596 OPERATION FOR CHRONIC APPENDICITIS. 

its longitudinal band. The finger is introduced and the 
appendix is sought for, and when found, if no adhesions 
exist, both the appendix and the caecum can be drawn out 
through the wound, the peritoneum being protected by 
one or two gauze pads. The meso-appendix is then ligated 
by passing a catgut ligature through its folds, near the 
junction of the appendix with the caecum, and tying it 
well below the attachment of the meso-appendix to the 
appendix. If the meso-appendix is large, it should be tied 
off in sections. The appendix is next separated from its 
mesentery and held upward by an assistant, while the 
surgeon surrounds its base by a silk or a fine chromicized 
catgut purse-string suture. When this is in place the end 
should be knotted, the knot tied and held by an assistant, 
while the surgeon divides the appendix about a quarter of 
an inch from the caecum. If the canal is patent, the 
opening is dilated by means of a small pair of fine-bladed 
forceps, and the stump inverted into the caecum by another 
pair of fine forceps grasping the cut margins and pushing 
them inward. An assistant then tightens the purse-string 
suture, and the small forceps is withdrawn. By this 
manipulation the stump is inverted and buried. In many 
cases there is so much infiltration of the caecum or appen- 
dix that it is difficult to accomplish a satisfactory inversion 
of the stump. In such cases the base of the appendix 
should be ligated and the appendix removed, and the ex- 
posed mucous surface should be touched with the actual cau- 
tery or with a drop of pure carbolic acid. A cuff of perito- 
neum maybe dissected from the appendix before it is ligated, 
and after this has been accomplished the cuff may be su- 
tured over the surface of the stump by two or three sutures 
of fine silk, or it may be buried by sutures applied as 
shown in Fig. 502 on page 593. After removal of the 
appendix the caecum should be carefully sponged with 
gauze and returned into the abdominal cavity. The peri- 
toneum is next closed with continuous suture of catgut or 
fine silk, and the muscular layers are next allowed to fall 
together, and are held in contact by a few interrupted cat- 
gut sutures. The aponeurosis is then brought together 



LITHOTOMY. 597 

with a few interrupted or continuous sutures, and the skin 
and connective tissue closed by sutures of silkworm-gut or 
catgut. If there is any question as to the contamination 
of the wound, a small cigarette drain should be introduced 
down to the stump of the appendix, and may be allowed 
to remain for twenty-four or forty-eight hours and then 
removed. 

Incision Through the Outer Edge of the Rectus 
Muscle. — This consists of an incision two and a half or 
three inches in length, over the outer portion of the rectus 
muscle, about half an inch from its external border. The 
skin and cellular tissue are divided, and the sheath of the 
muscle is exposed and opened in the direction of the cu- 
taneous incision, and the muscular fibres are retracted in- 
ward. This exposes the posterior wall of the sheath and 
the epigastric vessels, which may be retracted or divided. 
The posterior portion of the sheath is then opened, expos- 
ing the peritoneum and subserous connective tissue, which 
is picked up with two pairs of haemostatic forceps and 
carefully divided, opening the peritoneal cavity. The 
appendix is then sought for, and the steps of its removal 
are the same as previously described. 

LITHOTOMY. 

Left Lateral Lithotomy. — In performing this opera- 
tion, the patient is placed upon his back, the hands and 
feet are secured together, and the bladder is injected with 
a few ounces of boric acid solution. A grooved staff is 
introduced into the bladder, the operator first passing one 
finger into the rectum to locate the position of the staff 
as regards the prostate. An incision is then made a little 
to the left of the raphe of the perineum, a quarter to half 
an inch in front of the anus, and is carried downward by 
careful strokes of the knife until the staff is reached, about 
half an inch in front of the prostate. When the point of 
the knife enters the groove in the staff, it is pushed back- 
ward, keeping it well in the groove until the prostate is 
incised and a gush of fluid escapes along the knife, when 



598 



SUPRAPUBIC LITHOTOMY. 



it is removed and the index finger introduced and the 
stone located ; lithotomy forceps are next introduced and 
the stone removed (Fig. 503). 



Fig. 503. 




Deep incision in lateral lithotomy. (Fergvsson.) 



Suprapubic Lithotomy. — The operation of opening 
the bladder above the pubes may be performed for the 
removal of stone from the bladder, for the extirpation of 
growths, or for drainage of the bladder. The hair on the 
pubes should be shaved off, the bladder injected with a few 
ounces of saline solution, and a rubber band tied around 
the penis ; a small rubber bag is then introduced into the 
rectum empty and filled with air or water. An incision 
two or three inches in length is made in the median line 
of the abdomen just above the symphysis pubis, and is 
deepened gradually until the deep fascia is reached ; this 
is divided, exposing the prevesical fat ; when this is dis- 
placed, the wall of the bladder is exposed to view. A 
tenaculum is next introduced into the highest part of the 
vesical wall, to fix it, and a knife thrust through the wall 
of the bladder, the incision being carried downward about 
an inch. After the bladder is opened, forceps are intro- 
duced and the calculus removed. If opened for calculus 



CIRCUMCISION. 599 

and the bladder-walls are healthy, the wound may be 
sutured with stitches which do not pass through the 
mucous coat. The external wound is then sutured and 
the bladder drained by a soft catheter passed by the ure- 
thra. If the bladder-walls are much diseased, the wound 
is left open and drainage effected by a rubber tube passed 
through the suprapubic wound into the bladder. 

CIRCUMCISION. 

Circumcision is performed by drawing the prepuce for- 
ward and then enclosing it in a pair of clamp-forceps 

Fig. 504. 



Circumcision. 



placed obliquely just in front of the glans (Fig. 504). The 
prepuce is next divided with a straight bistoury, and the 
forceps removed, when the skin and mucous membrane 
retract. The mucous membrane, if adherent, is dissected 
loose from the glans; if redundant, it is trimmed with 
scissors to make it correspond to the line of skin incision ; 
the cut edge of the mucous membrane is next fastened to 
the cut edge of the skin by a few sutures of silk or catgut. 



600 TREATMENT OF HYDROCELE. 



REMOVAL OF THE TESTICLE. 

In removing the testicle, a longitudinal incision is made 
over the upper part of the gland and spermatic cord and 
the envelopes of the testicle and cord divided ; the cord is 
then exposed and ligated, or the different components of 
the cord may be separated and tied independently ; the 
cord is divided in advance of the ligatures and the gland 
removed. 

OPERATION FOR VARICOCELE. 

In operating for varicocele the veins of the spermatic 
cord may be exposed by an incision an inch and a half or 
two inches in length, at the upper part of the scrotum, 
over the cord, or the cord may be exposed by an incision 
as it emerges from the inguinal canal. The veins being 
exposed, the larger portion of them are isolated, and two 
ligatures are passed around the mass of veins about an 
inch or an inch and a half apart and firmly tied, care 
being taken that the vas deferens is not included with the 
veins. The portion of the cord between the ligatures is 
excised and the divided ends of the veins brought in con- 
tact by tying together the ends of the ligatures upon the 
proximal and distal ends of the veins ; the wound is then 
closed with sutures. 

TREATMENT OF HYDROCELE. 

The Palliative Treatment. — The skin of the scrotum 
should be sterilized and the tumor rendered tense by 
grasping it with the hand; a sterile trocar is then intro- 
duced through the anterior Avail of the scrotum into the 
cyst, being directed upward and backward to avoid wound- 
ing the testicle. After the fluid has escaped the canula is 
removed and the puncture sealed with a sterile piece of 
gauze or cotton and collodion. 

The Radical Treatment. — This consists in emptying 
the cyst by means of a trocar and injecting from 1 to 2 



CHOLECYSTOTOMY. 601 

drachms of tincture of iodine. Another method consists in 
first introducing the needle of a hypodermic syringe, charged 
with 10 to 15 drops of pure carbolic acid, into the upper 
part of the sac — this is held by an assistant. The sac is 
next emptied by introducing a trocar at a lower portion of 
the cyst. After removing the fluid the carbolic acid is 
injected into the cyst and evenly distributed by rubbing 
the walls together. The instruments are removed and the 
punctures sealed with gauze and collodion. Pain and 
swelling follow each of these operations, but usually 
subside in forty-eight hours. 

Excision of the Sac. — This consists in making an in- 
cision two to three inches in length over the anterior sur- 
face of the scrotal tumor, and dividing the tissues until 
the sac is exposed. This is next incised, and the parietal 
layer is dissected out as far as possible; a strip of rubber 
tissue or a gauze pack is introduced and allowed to remain 
for forty-eight hours and is then removed. The wound 
usually heals in from ten days to two weeks. 

CHOLECYSTOTOMY. 

This operation consists in opening the gall-bladder for 
exploration or for the removal of gall-stones. 

An incision three or four inches in length is made verti- 
cally downward along the outer edge of the right rectus 
muscle from the lower border of the eighth rib to a point 
opposite the umbilicus ; the tissues are divided and the 
peritoneum opened. The gall-bladder is then exposed and 
drawn upward in the wound and the peritoneum protected 
by gauze pads. An incision is then made in the fundus 
and the stone removed, after which the opening in the gall- 
bladder is closed with two layers of Lembert sutures, the 
parts disinfected, and the organ returned to the abdominal 
cavity ; the latter is next closed by sutures, or the gall- 
bladder may be sutured to the subcutaneous tissues of the 
external wound and then opened and the stone removed, 
the wound being left open, a drainage-tube or gauze drain 
being introduced. If the gall-duct is to be explored, this 



602 CHOLECYSTOTOMY. 

is done with the finger from without or by a probe intro- 
duced into it through the gall-bladder. 

Cholecystostomy. — This operation is employed for 
drainage of the gall-bladder, which is exposed as in the 
operation of cholecystotomy. Two circular purse-string 
sutures are introduced into the peritoneal covering of the 
fundus of the gall-bladder ; the first suture is placed so as 
to include a circle about one-third of an inch in diameter, 
and the second is placed so as to secure the first about 
one-third of an inch from it. An incision is then made 
within the inner circle and a rubber drainage-tube passed 
into it. As the tube is introduced the first suture is tight- 
ened and tied, and as the tube is pushed further inward it 
carries with it a funnel-like depression of the fundus, when 
it is tied. The gall-bladder is then attached to the peri- 
toneum by one or two catgut sutures and the abdominal 
wound is partly closed by sutures. This method secures 
good drainage, and prevents leakage and the possibility of 
a permanent fistula after the drainage-tube has been re- 
moved. 

Cholecystectomy. — The gall-bladder is exposed as in 
the previous operation, the cystic duct is located, and two 
ligatures of silk or chromicized catgut are passed around 
it. The peritoneal covering of the gall-bladder is incised 
at its junction with the liver, and the gall-bladder is sepa- 
rated from the under surface of the liver by a blunt dis- 
section. When entirely separated from the liver, the cystic 
duct is divided between the two ligatures and the organ 
is removed. Hemorrhage is controlled by ligatures or by 
gauze packing. The abdominal wound is next partly 
closed, a gauze packing being allowed to remain in the 
wound in contact with the raw surface of the liver. 

Choledochotomy. — This operation consists in opening 
the bile-duct for the removal of a stone or for drainage. 
A long incision, extending as high as possible, is made 
through the right rectus muscle, and the gall-bladder region 
is freely exposed. The intestines are next walled off with 
gauze packing. The operator introduces the left hand 
into the wound and carries the index finger through the 



EXTERNAL (ESOPHAGOTOMY. 603 

foramen of Winslow into the lesser peritoneal sac. With 
the finger in the foramen, the cystic, hepatic, and common 
ducts can be examined, and if a stone is felt the duct is 
raised upon the finger and brought near the surface of the 
wound. When the stone is located the duct is exposed by 
the removal of the peritoneal covering and incised longi- 
tudinally, and the stone removed. A probe is next passed 
into the duct in both directions to insure its patency, and 
if there is no reason to suspect infection of the duct, the 
wound is closed by a few fine silk sutures introduced with 
a round, curved needle. A small gauze drain or cigarette 
drain is then carried down to the wound, and after remov- 
ing the gauze packing the abdominal wound is partly 
closed by sutures. If the duct is found infected, a small 
drainage-tube is introduced into the duct and secured by a 
single catgut suture, the gauze packing is removed and re- 
placed by new packing, and the abdominal wound is par- 
tially closed. 

Cholecystenterostomy. — This operation is employed 
in cases of complete and permanent obstruction of the 
common duct, and consists in anastomozing the fundus of 
the gall-bladder to the second portion of the duodenum. 
Sometimes from misplacement or 'diminished size of the 
gall-bladder or adhesions, it may be necessary to make the 
communication with the jejunum or hepatic flexure of the 
colon. The gall-bladder is exposed by the ordinary in- 
cision, and the anastomosis is effected by means of a small 
Murphy button. The line of union, after the anastomosis 
has been made, may be strengthened by wrapping a mass 
of omentum around it and securing it in place by a few 
catgut sutures. 

EXTERNAL (ESOPHAGOTOMY. 

A sound is passed through the mouth into the oesopha- 
gus until its point comes in contact with the stricture of 
the ceosphagus or the foreign body which requires removal. 
An incision is then made from a point one inch above the 
sternum to the line of the upper border of the thyroid 



604 OPERATIONS UPON STOMACH AND INTESTINES. 

cartilage on the inner side of the sterno-cleido-mastoid 
muscle ; the anterior jugular vein is displaced, the fascia is 
divided, the omohyoid muscle is drawn aside, the sterno- 
mastoid muscle and the vessels are drawn to the outer side 
with blunt hooks, and by dissecting down with the finger 
the oesophagus is exposed ; the sound which has been 
passed into the oesophagus may easily be felt, and the 
oesophagus incised upon the point of this sound. If a 
permanent opening is desired, the edges of the oesophagus 
are sutured to the skin. 



OPERATIONS UPON THE STOMACH AND IN- 
TESTINES. 

GASTROSTOMY. 

An incision one and a half to two inches in length is 
made parallel to and a finger's breadth from the border of 
the left costal cartilage, ending opposite the border of the 
tenth rib ; the tissues are divided layer by layer until the 
peritoneum is reached (Fig. 505). The latter membrane 

Fig. 505. 



Anatomical relations of the stomach. (Stimson.) 

should be pinched up and opened ; the stomach is recog- 
nized and brought out of the wound ; the parietal perito- 
neum is stitched to the skin around the wound, and a fold 
of the unopened stomach is brought out of the wound 
and sutured to the parietal peritoneum and the abdominal 



GASTROSTOMY. 



605 



wall. The opening of the stomach is delayed for twenty- 
four hours, if possible, to allow of the formation of adhe- 
sions between its surface and the parietal peritoneum. 

Fig. 506. 




/ 

Ssabanajew-Frank method ; first stage. (Richardson.) 

Ssabanajew-Frank Method. — A curved incision, three or 
four inches in length, is made at the margin of the costal 
cartilages of the left side, and the surface of the stomach 
is exposed. A cone of the stomach-wall is then grasped 
with forceps, pulled out of the wound (Fig. 506), and passed 
under a bridge of skin and connective tissue and made to ' 
project from a separate wound made about one and a half 
inches above the original wound (Fig. 507), The wall of 
the stomach is fastened in the original wound by sutures 
and the wound closed, the projecting portion of the stom- 
ach in the upper wound being secured by sutures. The 
stomach may be opened at any time. 



606 



GASTROSTOMY. 
Fig. 507. 




Ssabanajew-Frank method ; second stage. (Richardson.) 
Fig. 508. 




Witzel method of infolding the tube. (Richardson.) 



PYLOROPLASTY. 



607 



Witzel's Method. — This method of gastrostomy also pre- 
vents leakage, and is accomplished by making an incision 
and exposing the wall of the stomach. A small incision 
is made in the wall of the stomach and a rubber tube or 
catheter introduced ; the portion of the tube in contact 
with the stomach external to the wound is then infolded 



Fig. 509. 




Witzel method ; tube infolded and sutures introduced to close the wound. 
^Richardson.) 

by peritoneal approximation, as shown in Fig. 508. The 
stomach is then stitched to the abdominal wall and the 
external wound closed (Fig. 509). The tube should not 
be removed for a week ; feeding may be begun through 
the tube immediately. Contraction of the fistula may be 
prevented by the occasional introduction of the tube or 

catheter. 

PYLOROPLASTY. 

This operation is practised in non-malignant strictures 
of the pylorus. The pyloric extremity of the stomach is 



608 



PYLOROPLASTY. 



exposed by a median incision, and a longitudinal incision 
is made through the anterior surface of the constricted 
pylorus (Fig. 510), and the incision closed by sutures 
introduced transversely, as shown in Fig. 511. 

Finney's Method. — In this method the region of the 



Fig. 510. 




Incision in pyloroplasty. (Richardson.) 
Fig. 511. 




Incision closed transversely by sutures. (Richardson.) 

pylorus is freed from all adhesions, and a heavy silk liga- 
ture is introduced at the summit of the pylorus to act as 
a retractor, and another through the anterior wall of the 
stomach about three inches from the first one., and a third 



PYLOROPLASTY. 



609 



ligature is passed through the anterior wall of the duode- 
num at the same distance from the pylorus. By making 
traction upon the first ligature upwards and upon the two 
others downwards, the anterior surface of the duodenum 
and stomach are brought into contact and united by a row 



Fig. 512. 




Finney's operation: position of ligatures. (Brewer.) 



of fine silk sutures passed through the peritoneal coats of 
the viscera (Fig. 512). An inverted U-shaped incision is 
next made through the walls of the stomach, pylorus, and 
duodenum about half an inch from the line of sutures. The 
adjacent mucous and muscular coats of the duodenum and 
stomach are united by a continuous suture of catgut and 
the opening is next closed by a layer of mattress sutures 
(Fig. 513). 



39 



T 



610 



PYLOROPLASTY. 
Fig. 513. 




Finney's operation : sutures in place. (Brewer.) 
Fig. 514. 




Lines of incision for excision of pylorus. (Richardson.) 



PYLORECTOMY AND GASTRO-DUODENOSTOMY. 611 



PYLORECTOMY AND GASTRO-DUODENOSTOMY. 

This operation is practised in malignant strictures of 
the pylorus. It consists in exposing the stomach and 
duodenum by a median abdominal incision ; the upper 



Fig. 515. 




Pylorus excised and opening into the stomach partially closed. (Richardson.) 

portion of the duodenum and the stomach are drawn 
through the incision, and resection of the diseased portion 
accomplished (Fig. 514). The opening in the stomach 
being much larger than that resulting from resection of 
the duodenum, the wound in the stomach should be par- 
tially closed by Lembert sutures (Fig. 515); and when it 
has been reduced to a proper size to fit the free end of the 
duodenum, they are fitted together and held in position 
by the introduction of a circular row of closely applied 
Lembert sutures (Fig. 516). 



612 



G A STR O-ENTER OSTOMY. 
Fig. 516. 




Gastro-duodenostomy completed. (Richardson.) 



GASTROENTEROSTOMY. 

This operation may be combined with pylorectomy, or 
in cases where it is inadvisable to resect the pylorus, a 
lateral anastomosis between the stomach and a coil of 
small intestine near the stomach may be made, so that the 
contents of the stomach may find their way into the intes- 
tine through this artificial opening. Where resection of 
the pylorus is combined with gastroenterostomy, the 
method of closing the duodenum and stomach and of anas- 
tomosis between the intestine and the stomach are shown 
in Fig. 517. (For other methods of gastroenterostomy, 
see pp. 620, 621.) 

Enterotomy. — This consists in an incision into the 
large or small intestine for the purpose of diagnosis or for 
the removal of tumors or foreign bodies. The abdomen 
is opened by the ordinary incision and the bow T el is drawn 
into the wound, gauze pads being packed around it to pro- 
tect the peritoneal cavity. The bowel is incised in the 



GASTROENTEROSTOMY. 



613 



longitudinal direction and the wound is closed with fine 
silk Lenibert sutures. 

Enterectomy. — This consists in removing a section of 
the intestine for extensive wounds or gangrene of the gut, 
for the removal of a growth, for stricture, or for the treat- 
ment of a fecal fistula. The bowel is exposed by the ordi- 
nary abdominal incision and the portion of the bowel to be 
removed is drawn out of the abdomen ; the peritoneal cavity 



Fig. 517. 




Pyloreetomy and gastroenterostomy. (Richardson.) 

being protected by gauze pads. The lumen of the bowel, 
above and below the area to be removed, is closed by clamps 
protected by rubber or by gauze ligatures. An incision, 
V-shaped, including the intestine and a portion of the mesen- 
tery, is next made, and after ligating any bleeding vessels 
the mucous edges of the gut are disinfected by bichloride 
solution. The ends of the gut are finally approximated by 
sutures, circular enterorrhaphy, or by the Murphy button. 



614 METHODS OF INTESTINAL ANASTOMOSIS. 



METHODS OF INTESTINAL ANASTOMOSIS. 

Circular Suture of Intestine. — After division or resec- 
tion of the intestine the ends may be united by sutures. 

Fig. 518. 



Circular, or end-to-end suture of the intestine. (Richardson.) 

Interrupted Lembert sutures are usually employed. The 
sutures should first be applied at the mesenteric border, 



Fig. 519. 




The Murphy button. 



THE MURPHY BUTTON. 



615 



and great care should be exercised to make the apposition 
close at this point. The ends of the bowel should then 
be brought together with closely applied Lembert sutures. 
If the mesentery has been divided, it should also be ap- 
proximateed by sutures (Fig. 518). 

The Murphy Button. — This is a mechanical contrivance 
which may be employed to secure end-to-end apposition of 

Fig. 520. 




The two portions of the Murphy button held in place by purse-string sutures. 
(Richardson.) 

the divided intestine, or may be used to form a lateral 
Fig. 521. 




End-to-end union of intestine with Murphy's button. (Richardson.) 



anastomosis between the intestines or hollow viscera. 
The construction of the button is shown in Fig. 519). 



616 



SENN'S METHOD. 



This method of end-to-end approximation or anastomo- 
sis can be accomplished with accuracy and with great 
rapidity. In employing the button for these purposes, it is 
separated into its two parts, and each part is slipped into 



Ficx. 522. 




End-to-end approximation, button in position. (Richardson.) 

the divided end of the intestine and secured by a purse- 
string suture (Fig. 520j. and the parts are approximated 
by fastening the two portions of the button together (Figs. 
521 and 522). Where lateral anastomosis between the 
intestines, or between the intestine and another hollow 
viscus, is desired, an incision is made in each organ, and 
half of the button is slipped into each opening and secured 
by a purse-string suture, and the portions of the button are 
then fastened together. Union of the peritoneal surfaces 
results, and the button is usually released in from ten to 
twelve days by sloughing of the included tissues, and is 
passed by the anus. 

Senn's Method. — When it is desired to form a perma- 
nent orifice between two portions of the gut or other 
hollow viscera, the ends of the gut are closed, and an 
opening is made in each portion of the gut, into which 
the perforated bone plates of decalcified bone are slipped, 



LATERAL ANASTOMOSIS. 



617 



and the walls of the gut surrounding the openings are 
held in contact with each other by sutures attached to the 
perforated plates. To accomplish the same purpose, rubber 
rings or perforated plates of rubber have been employed ; 
also rings made from catgut, to which the sutures are 
attached, in the same manner as Senn's plates ; and if 
catgut rings are employed, these will be softened and dis- 
solved in a short time so as to be passed without difficulty. 
Abbe's Method of Lateral Anastomosis. — Portions 



Fig. 523. 




Lateral anastomosis. First stage of operation. (Richardson.) 

of the intestinal tract more or less distant, or the intestine 
and the stomach, may be united by this procedure, thus 
permitting the contents to pass through the new opening. 
The bowel upon each side of the constricted portion is 
manipulated, so that both portions lie side by side; or, in 
case a portion of the bowel has been removed, the ends 
are inverted and closed by Lembert's sutures. The two 
portions of the bowel are brought side by side, and a 
longitudinal cut three inches in length, opposite the mes- 



618 



CIRCULAR EXTERORRAPHY. 



enteric attachment, is made through the coils to be united. 
The posterior edges of the incision should first be brought 
together by continuous or interrupted sutures (Fig. 523). 

The margins of the incision may be hemmed before 
uniting them. The anterior edges of the incision are next 
united by another continuous stitch, and for additional 
security a second line of interrupted or continuous 
sutures may be applied (Fig. 524). The time required 



Fig. 524. 




Lateral anastornosi 



tion completed. (Eichardson.) 



for the application of the sutures is one disadvantage of 
this operation. 

Intestinal anastomosis by this method may be employed 
instead of the circular suture in wounds completely divid- 
ing the intestine, and after resection of the intestine for 
the removal of growths or for stricture. 

Circular Enterorraphy. — This consists in an end-to- 
end union of a divided bowel. The edges of the bowel 
are approximated and united with two layers of sutures ; 



CARGILE MEMBRANE. 619 

the first set of sutures of catgut unite the mucous mem- 
brane and muscular coats of the bowel, the second layer 
unites the peritoneum. Lembert sutures should be used, 
and care should be taken to secure complete closure of that 
portion of the bowel between the layers of the mesentery, 
as there is no peritoneum to unite at that point. At this 
point a small portion of the mesentery may be inverted to 
insure early adhesion, and both sides of the mesentery 
should be united by Lembert sutures. 

Anastomosis or End-to-end Approximation by La- 
place's Forceps. — Laplace has recently devised a forceps 
by which end-to-end approximation or lateral anastomosis 
can be accomplished with great accuracy and rapidity. 
The forceps are of different sizes according to the 
parts to be united, and consist of two parts, which are 
really haemostatic forceps curved into a semicircle on each 
side and held together by means of a clasp ; they open 
as two rings. They hold together the parts to be united, 
and serve the same purpose as Senn's bone plates, keeping 
the serous surfaces in contact. The sutures are intro- 
duced at all points except where the forceps penetrate the 
parts that are sutured. The sutures having been intro- 
duced, the forceps are released by loosening the clasp and 
withdrawing the forceps, first one half and then the other 
half, and the small opening is finally closed by one or 
two sutures. These forceps may be used in end-to-end 
approximation, lateral anastomosis, or gastroenterostomy. 
The forceps devised by O'Hara and by Allis are less com- 
plicated and have been used with equally good results. 

Cargile Membrane. — This material, in the form of a 
thin transparent membrane, is prepared from the perito- 
neum of the ox. It is employed to cover portions of the 
intestines or other abdominal viscera which have been de- 
nuded of peritoneum, and thus prevent adhesions. The 
membrane should be thoroughly sterilized, and when 
applied to the defect should be held in place by a few 
sutures of fine silk or catgut. It has also been employed 
in plastic operations upon the nerves or tendons to prevent 
the formation of adhesions to the surrounding tissues. Some 



620 GASTROENTEROSTOMY WITH ELASTIC LIGATURE. 

difference of opinion exists as to its utility by different ob- 
servers. 

Harrington's Segmented Ring. — This device, which 
is employed for end-to-end anastomosis, lateral anasto- 
mosis, and gastroenterostomy, consists of aluminum rings 
made of different sizes, the largest less than an inch in diam- 
eter, in four sections, which are held together by a screw 
at the end of a handle (Fig. 525). 

Fig. 525. 




Harrington's segmented ring. 

Purse-string sutures of silk or catgut are introduced 
into the ends of the intestine to be united after introducing 
the ring into each end of the intestine. These sutures are 
firmly tied in the groove of the ring and the peritoneal 
surface of the gut is approximated by a layer of Lembert 
sutures. After applying the sutures the handle of the 
ring is carefully removed by turning the screw, and a su- 
ture is introduced into the gut at the part where the handle 
is removed. The purse-string sutures hold the ring in place 
until the sutures soften ; or if it is desired to immediately sep- 
arate the segments of the ring, it may be done by gentle ma- 
nipulation upon the ring through the walls of the intestine. 



GASTROENTEROSTOMY WITH ELASTIC LIGATURE. 

This procedure, devised by McGraw, which has been em- 
ployed in a considerable number of cases with success, may 
be used in gastroenterostomy or entero-enterostomy. A 
round rubber ligature 2 mm. in diameter is employed. 
The walls of the stomach and of the intestine are first 
united by a posterior row of Lembert sutures. A long 
straight needle armed with the rubber ligature is passed 



OPERATION FOR STRANGULATED HERNIA. 621 

into the lumen of the bowel and brought out at a point 5 
to 10 cm. distant from the site of its introduction. 

An assistant holds the intestine, and the surgeon stretches 
the ligature in the needle and when it is quite thin draws 
it through the intestine ; the same procedure is repeated in 
passing the ligature through the walls of the stomach. A 
strong silk ligature is next placed across and beneath the 
rubber ligature, between the latter and the point where the 
stomach and intestine come in contact. The rubber lig- 
ature is then drawn tight and tied with a single knot ; the 
silk ligature is passed around the ends of the ligature where 
they cross and is firmly tied with three knots, and the ends 
of the elastic ligature are released and cut off. An anterior 
row of Lembert sutures are then applied to make the 
junction between the stomach and intestine complete. 
The operator should be careful not to tie the rubber lig- 
ature too far backward and thus place it behind the poste- 
rior row of Lembert sutures. 

GASTROENTEROSTOMY WITH MURPHY BUTTON. 

The viscera are exposed by the usual incision, and the 
jejunum is found and carried in front of the great omentum 
and transverse colon and brought in contact with a non-vas- 
cular part of the greater curvature of the stomach. The wall 
of the stomach is incised and the male half of the button is 
inserted and secured by a purse-string suture. The female 
half of the button is next inserted into the jejunum opposite 
the mesenteric attachment and secured in the same manner. 
The two halves of the button are approximated in the usual 
manner ; the button-anastomosis may be reinforced by a few 
Lembert sutures. 

OPERATION FOR STRANGULATED HERNIA. 

This consists in an incision over the hernial swelling, 
with careful dissection of the various layers until the sac 
is reached. The sac should then be freely opened and its 
contents examined. If the bowel is dark and without 
lustre, gangrene is present, but if the gut is dark and 
retains its lustre, it may be restored by the relief of the 



622 OPERATION FOR CURE OF FEMORAL HERNIA. 

strangulation. If the sac contains a fair amount of blood- 
stained serum, the bowel is usually found in good condition 
as regards viability. The surgeon should next locate the 
point of constriction of the bowel and divide it, either from 
within by means of a small, blunt-pointed hernial knife, 
or better, by a careful dissection from without, dividing all 
overlying tissues. When the constriction has been re- 
lieved, the bowel should be drawn well down into the 
wound. If the color of the bowel improves after division 
of the stricture, it should be irrigated with warm salt so- 
lution, dried and returned into the abdominal cavity, the 
wound closed, and a gauze dressing applied. If the bowel 
is gangrenous, the gangrenous portion should be resected, 
and an end-to-end anastamosis should be made with su- 
tures or by the use of Murphy's button. If the condition 
of the patient is such that this procedure is not advisable, 
the bowels should be incised and the wound allowed to 
remain open for the formation of a fecal fistula. In many 
cases the operation for radical cure may be performed im- 
mediately after the relief of a strangulated hernia. 



OPERATION FOR THE RADICAL CURE OF FEMORAL 

HERNIA. 

Bassini's method consists in making an incision parallel 
with, and just below Poupart's ligament, with the centre 
over the saphenous opening. The skin and superficial 
fascia are incised and the edges of the saphenous opening 
exposed. The hernial sac is then exposed and dissected out 
of its canal to as high a point as possible. The sac is next 
opened and its contents returned to the abdominal cavity ; 
it is then drawn well downward and its neck transfixed 
with a double ligature of chromicized catgut ; the ends of 
the ligature are crossed, and the neck of the sac is ligated 
and cut off below the ligatures. The stump is then re- 
turned into the abdomen. Sutures of kangaroo tendon or 
chromicized catgut, carried by a curved needle, are intro- 
duced to approximate Poupart's ligament to the pectineal 
fascia, the first suture near the pubic spine, the second a 



OPERATION FOR CURE OF FEMORAL HERNIA. 623 

quarter of an inch to the outer side of the first, and the 
third about three-quarters of an inch to the inner side of 
the femoral vein ; these sutures passing through the pecti- 
neal fascia below. These sutures are left untied. Three 
or four sutures are next passed through the falciform proc- 
ess of the iliac portion of the fascia lata externally and 
the pectineal fascia ; the lowest suture passes just above 
the saphenous vein (Fig. 526). The three upper sutures 



Fig. 526. 




Operation for the radical cure of femoral hernia (Bassini's method) : a, 
falciform process; b, pubic portion of fascia lata; c, Poupart's ligament. 
(Bryant.) 

are next tightened and tied, and Poupart's ligament drawn 
backward to the linea pectinea. The lower sutures are 
next tightened and secured, and approximate the anterior 
and posterior walls of the femoral canal. The skin and 



624 OPERATION FOR CURE OF INGUINAL HERNIA. 

superficial fascia are then closed with catgut or silkworm- 
gut without drainage. A gauze dressing is applied over 
the wound and held in position by a spica bandage. 

Another method is that of Cushing, which consists in 
the introduction of a purse-string suture around the mar- 
gin of the saphenous opening, beginning and ending 
through the dense tissue of Poupart's ligament (Fig. 527). 



Fig. 527. 




Operation for the radical cure of femoral hernia: purse-string suture (Cush- 
ing's method.) (Bryant.) 



OPERATION FOR THE RADICAL CURE OF INGUINAL 
HERNIA. 

The Bassini operation is the one most usually employed, 
and consists in making an incision over the inguinal canal, 
parallel with Poupart's ligament, extending from a point 



OPERATION FOR CURE OF INGUINAL HERNIA. 625 

just above the outer side of the internal ring to a point 
one inch below and to the inner side of the spine of the 
pubis. The tissues are divided down to the aponeurosis of 
the external oblique muscle, and the external abdominal 
ring is exposed. A director is next introduced into the 
canal through the external ring, and the aponeurosis is di- 
vided in the direction of its fibres to the upper limit of the 
incision. The lower flap is everted and the structure sep- 
arated from its inner surface, exposing Poupart's ligament. 
The spermatic cord and the sac of the hernia are then sep- 
arated by division and removal of the various tunics, and 



Fig. 528. 




Operation for the radical cure of inguinal hernia (Bassini's methods : a, 
sac dissected from the cord and neck ligated : b, cord ; c. Poupart's ligament ; 
d, arched fibres of internal oblique muscle: <?, transversalis fascia. (Bryant.) 

the cord is retracted. After the sac has been isolated from 
the surrounding tissues and opened, to insure that it con- 
tains no intestine or omentum, its neck is drawn outward 
and ligated with a transfixion suture of catgut, and the 
distal portion is excised (Fig. 528). The stump is allowed 

40 



626 OPERATION FOR CURE OF TNIGUNAL HERNIA. 

Fig. 529. 




Operation for the radical cure of inguinal hernia (Bassini's method) : sac 
removed (c), cord drawn aside, and stitching of lower fibres of the internal 
oblique and transversalis muscles (6) to Poupart's ligament (d) from without 
inward; a, transversalis fascia. (Bey ant.) 

Fig. 530. 




Operation for the radical cure of inguinal hernia (Bassini's method;: 
arched muscular fibres and conjoined tendon (b) sewed to Poupart' ligament 
(a) ; c, aponeurosis of external oblique muscle. (Bryant.) 



OPERATION FOR CURE OF INGUINAL HERNIA. 627 

to fall back into the abdominal cavity. The cord is held 
up out of the wound by a retractor or loop of gauze, and 
a number of deep sutures of kangaroo tendon or chromi- 
cized catgut are next passed through the lower border of the 
internal oblique muscle, and the portion of Poupart's lig- 
ament which is exposed by inverting the inferior flap of the 
aponeurosis of the external oblique (Fig. 529). After the 
sutures have been tightened and secured, reconstructing 
the floor of the inguinal canal, the cord is allowed to drop 
into place (Fig. 530). The roof of the canal is recon- 

Fig. 531. 




Operation for the radical cure of inguinal hernia (Bassini's method) : 
aponeurosis of external oblique (a) sewed with continuous sutures to Pou- 
parfs ligament (b). (Bryant.) 

structed by uniting the divided external oblique aponeu- 
rosis. This may be done with a continuous or interrupted 
suture of fine catgut, and the closure should be complete 
enough to leave only the external ring open sufficiently to 
allow the cord to pass outward without causing constriction. 
(Fig. 531). The skin and connective tissue should then 



628 OPERATION FOR CURE OF UMBILICAL HERNIA. 

be closed with catgut or silkworm-gut sutures, and a gauze 
dressing applied and held in position by a spica bandage. 



OPERATION FOR THE RADICAL CURE OF UMBILICAL 
HERNIA. 

An elliptical incision is made over the hernia, with upper 
and lower ends in the median line, the width of the ellipse 
depending upon the size of the hernia. The incision is 
first carried through the skin and fascia only, then 
deepened until the abdominal aponeurosis is reached, 
just outside of the hernial neck. The hernial sac is then 
exposed and opened, and if it contains a mass of omentum, 
this is ligated, and the bowel is returned into the abdomen 
and kept in place by a gauze pad. The entire sac, with 
the umbilicus and the coverings, is then excised, dividing 
the peritoneum in an elliptical manner about the neck of 
the sac. The edges of the peritoneum and the transver- 
salis fascia are next sutured with. interrupted or continuous 
catgut sutures ; the borders of the abdominal ring, which 
consist of the sheath and margins of the recti muscles, are 
then freshened and the edges brought together with inter- 
rupted sutures of kangaroo tendon or chromieized catgut. 
The skin and fascia are then approximated with inter- 
rupted silkworm-gut sutures. A gauze dressing is then 
placed over the wound and held in place by a firmly ap- 
plied abdominal bandage. 

Blake's Method. — This consists in making a large ellip- 
tical incision around the hernia and removing the connec- 
tive tissue so as to expose a large area of the aponeurosis. 
The sac is excised and the edges are brought together with 
sutures. The linea alba is next divided to the upper and 
lower limits of the skin incision. The peritoneum is next 
separated from the abdominal wall on one side, and the 
muscular and aponeurotic flap thus formed is drawn to the 
opposite rectus muscle and secured by the layer of mattress 
sutures of chromieized catgut. The first layer of sutures 
unites the free border of the overlapped flap to the over- 



OPERATION FOR CURE OF UMBILICAL HERNIA. 629 

lapping wall by through-and-through sutures, the second 
layer unites the free borders of the superficial to the deeper 

Fig. 532. 




Blake's operation for the radical cure of umbilical hernia. (Brewer.) 



wall by sutures which do not penetrate the peritoneal cav- 
ity. The skin wound is finally closed without drainage. 



INDEX. 



ABDOMEN, bandage of, many- 
tailed, 32 

Abdominal aorta, ligation of, 469 
bandage, 32 
nephrectomy, 588 

Abscess, acute, treatment of, 259 
chronic, treatment of, 260 
Hilton's method in, 259 
treatment of, 259 
tuberculous, aspiration in, 260 
incision in, 261 
injection in, 261 
iodoform emulsion in, 261 
puncture in, 261 
treatment of, 260 

Absorbent cotton, 116 

Acetanilid, 354 

Acetate of aluminum, 305 

Acid, boric, 306 
carbolic, 301 

picric, dressing in burns, 273 
salicylic, 306 

Acromion process of scapula, frac- 
ture of, 370 

Actinomyces, 293 

Actual cautery, 137 

in venous hemorrhage, 253 

Acupressure in arterial hemor- 
rhage, 251 

Acute abscess, treatment of, 259 

Adductor longus tendon, tenotomy 
of, 569 

Adhesive plaster, 118 

Adrenalin chloride in arterial hem- 
orrhage, 246 

Aluminum acetate, 305 

Amputating knives, 486 
saws, 487 

Amputation or Amputations, 481 
above shoulder-joint, 509 
at ankle-joint, 518 



Amputation at ankle-joint, Piro- 
goff's, 519 

Koux's, 520 
of arm, 503 

circular, 503 

by lateral flaps, 504 

modified circular, 504 

by transfixion, 503 
Bier's osteoplastic method, 485 
carpo-metacarpal, 499 
circular, 481 
details of, 491 
at elbow, 501 

anterior flap, 501 

circular, 502 

elliptical, 503 

lateral flaps, 501 
elliptical, 483 
of fingers, 494 
of foot, 511 

Chopart's, 517 

Hancock's, 521 

Key's, 517 

Lisfranc's, 516 

Mikulicz's, 521 

subastragaloid, 518 

Tripier's, 521 
of forearm, 500 

circular, 500 

modified circular, 501 
of hand, 494 
at hip-joint, 529 

by lateral flaps, 532 

modified circular, 531 

by transfixion, 530 

Wyeth's method, 532 
instruments for, 486 
at knee-joint, 525 

anterior flap, 526 

Carden's, 526 

elliptical flaps, 525 

631 



632 



INDEX. 



Amputation at knee-joint, Gritti's, 
527 

lateral flaps, 527 

through condyles of femur, 526 
of leg, 521 

circular, 522 

elliptical, 522 

flap method, anterior, 522 

antero-posterior, 524 

external, 525 

lateral, 524 

rectangular, 524 

modified circular, 522 

Sedillot's, 525 

Teale's, 524 
ligatures in, 490 
medio-tarsal, 517 
of metacarpal bones, 497 
metacarpo-phalangeal, 495 
of metatarsal bones, 513 
modified circular, 483 
oval, 483 

periosteal flaps in, 486 
redressing of, 492 
retractors in, 489 
at shoulder-joint, 505 

Dupuytren's, 507 

Larrey's, 506 

Lisfranc's, 508 

Spence's, 509 

Wyeth's pins in, 506 
sutures in, 490 
tarso-metatarsal, 514 
Teale's method in, 484 
of thigh, 527 et seq. 

by anterior flap, 527 

modified circular, 527 

through the trochanters, 529 

by transfixion, 529 
of toes, 511 
tourniquets in, 490 
transfixion method in, 482 
at wrist, 499 

circular, 499 

flap method, 499 

lateral flaps, 500 
Anaesthesia from chloride of ethvl, 

183 
from cocaine, 184 
from cold, 183 
general, 183 



Anaesthesia from kelene, 183 

local, 182 

from rapid respiration, 184 

regional, 183 

from scopolamine hydrobromate, 
205 
Anaesthetics, 182 

in fracture, 344 
Anastomosis forceps, 619 

intestinal, 614 
Ankle, dislocation of, 444 
Ankle-joint, amputation at, 518 

excision of, 551 

strapping of, 125 
Anterior crural nerve, exposure of, 
567 

figure-of-eight bandage of chest, 

. ?° 

tibial artery, ligation of, 476 

tendon, tenotomy of, 569 
Antipvrin in arterial hemorrhage, 

246 
Antisepsis, 281 

Antiseptic dressings, improvised, 
317 
operation, details of, 330 
poultice, 128 
Antitoxin, 288 

injection of, 163 
Antrum of Hi^hmore, trephining 

of, 559 
Aorta, abdominal, ligation of, 469 
Appendicitis, acute, operation for, 
593 ' 
chronic, operation for, 595 
incision through rectus muscle, 

597 
McBurney's operation for, 595 
Approximation sutures, 220 
Aqua ammonia as a rubefacient, 
135 
as a vesicant, 137 
Aristol, 307 

Arm, amputation of, 503 
and chest bandage, 68 
spiral reversed bandage of, 58 
Arterial hemorrhage. See under 
Hemorrhage, arterial, 2 ' 
transfusion, 147 
Arteriotomv, 146 
Artery forceps, 248, 488 



INDEX. 



633 



Artery or Arteries, ligation of, 451. 
See under each artery, 
suture of, 250 
wounded, ligation of, 252 
Arthrectomy of knee-joint, 549 
Artificial respiration, 149 
direct, 150 

Laborde's metbod, 154 
Silvester's metbod, 152 
Asepsis, 281 

agents to secure, 299 
from heat, 299 
Aseptic dressings, improvised, 317 
metbod, 298 
operation, details of, 328 
materials in, 308 et seq. 
preparation for, 321 
of patient for, 321 
of room for, 321 
Aspiration, 155 

in tuberculous abscess, 260 
Aspirator, Potain's, 155 
Astragalus, excision of, 552 
Auto-transfusion, 147 
Axillary artery, ligation of, 462 

BACILLUS aerogenes capsulatus, 
292 

anthracis, 291 

coli communis, 290 

of malignant oedema, 292 

mallei, 290 

of tetanus, 292 

tubercle, 290 
Back, strapping of, 126 
Bacteria, 281 

cultivation of, 284 

elimination of, 286 

entrance into tissues, 285 

infection by, 286 

inoculation by, 284 

intoxication by, 286 

pathogenic action of, 286 

resistance of tissues to, 287 

staining of, 284 

of suppuration, 289 

varieties of, 289 et seq. 
Bacteriology, surgical, 281 
Bandage or Bandages, 17 

abdominal, 32 
many-tailed, 32 



Bandage, arm and chest, 68 
Barton's, 42 

modified, 42 
black muslin, 94 
Borsch's, 89 
circular, 23 
compound, 27 
dimensions of, 20 
demi-gauntlet, 56 
Desault's, 65 
elastic webbing, 97 
Esmarch's, 243 
figure-of-eight, 26, 59 

of knee, 79, 81 

of leg, 85 

of neck and axilla, 63 
flannel, 93 
of foot, American, 83 

French, 84 
in fractures, 349 
gauntlet, 55 
gauze, 90 et seq. 
Gibson's, 45 
handkerchief, 33 
hardening, 98 
of head, 42 

and neck, 50 
Liebreich's, 88 
of lower extremity, 74 
many-tailed, 31 
oblique, 23 

of head, 53 
occipito-facial, 53 
occipito-frontal, 54 
paraffin, 112 

plaster-of-Paris, application of, 
100 

preparation of, 99 

for thigh and pelvis, 101 
recurrent, 27 

of stump, 87 
removal of, 22 
roller-, 18 
rubber, 94 
scissors, 22 
of Scultetus, 89 
for securing hands and feet, 88 
silicate of potassium, 111 

of sodium, 111 
spica, 26 

of buttock, 79 



634 



INDEX. 



Bandage, spica, of foot, 81 
of groin, ascending, 74 
descending, 76 
double, 77 
of shoulder, ascending, 60 

descending, 62 
of thumb, 57 
spiral, 23 
of chest, 70 
of finger, 55 
reversed, 24 
of arm, 58 
of leg, 84 

of lower extremity, 84 
of penis, 87 
of upper extremity, 58 
starched, 111 
sterilized, 317 
suspensory and compressor, of 

breast, 72 
of trunk, 70 
of upper extremity, 55 
varieties of, 23 
Velpeau's, 63 
Bandaging, rules for, 21 
Barton's bandage, 42 

modified, 42 
Bavarian dressing, 105 
Bedsores, 277 
Bellocq's canula, 256 
Beta-naphthol, 304 
Biceps flexor cruris tendon, tenot- 
omy of, 569 
Bichloride cotton, 317 
gauze, 316 
of mercury, 300 
Bier's osteoplastic method in ampu- 
tation, 485 
Binder's board splints, 113, 348 
Bis axillary cravat, 36, 
Black muslin bandage, 94 
Bladder, hemorrhage from, treat- 
ment of, 258 
implantation of ureter into, 591 
irrigation of, 218 
securing catheter in, 216 
sterilization of, 323 
Blood, transfusion of, 146 
Bloodletting, 140 
Bone chips, preparation of, 168 
forceps, 488 



Bone grafting, 167 

hyoid, fracture of, 359 

malar, fracture of, 355 

metacarpal, amputation of, 497 

nasal, fracture of, 354 

plates, preparation of, 168 
Boric acid, 306 
Borosalicylic powder, 306 
Borsch's eye bandage, 89 
Bougies, 213 

oesophageal, 158 

rectal, 160 

sterilization of, 210, 326 
Bow-legs, osteotomy for, 556 
Brachial artery, ligation of, 465 

plexus, exposure of, 565 
Breast, excision of, 573 
radical, 574 

suspensory bandage of, 38 

and compressor bandage of, 
72 
Bruises, 271 
Brush-burn, 272 
Buried suture, 225 
Burns, 272 

picric acid dressing in, 273 

white lead dressing in, 272 

x-ray, 276 
Buttock, spica bandage of, 79 
Button suture, 229 

CANTHAKIDAL collodion, 136 
Capillary hemorrhage, treat- 
ment of, 254 
Capsicum as a rubefacient, 135 
Carbolic acid, 301 
Carbolized gauze, 317 
Carden's amputation at knee-joint, 

526 
Cargile membrane, 619 
Carotid artery, common, ligation 
of, 457 
external, ligation of, 459 
internal, ligation of, 460 
Carpal bones, dislocation of, 435 

fracture of, 338 
Carpo-metacarpal amputation, 499 
Carpus, dislocation of, 435 
Cartilages, costal, dislocation of, 
421 
fracture of, 360 



INDEX. 



635 



Cartilages, semilunar, dislocations 

of, 444 
Catgut, boiled, 310 

chromic acid, 312 

chromicized, 312 

cumol, 311 

drainage, 314 

dry sterilized, 310 

Elsenberg's, 311 

formalin, 311 

iodine, 312 

ligatures, 310 

Von Bergmann's, 310 
Catheter, female, introduction of, 
216 

introduction of, 213 

male, securing of, in bladder, 216 

metallic, 211 

flexible, 211 

sterilization of, 210, 326 
Catheterization, permanent, 216 
Cauterization in arterial hemor- 
rhage, 248 

of ureters in female, 216 
Cautery, actual, 137 

in venous hemorrhage, 253 

irons, 138 
Celluloid thread, 313 
Cigarette drain, 314 
Circular amputations, 481 
Chain-stitch suture, 226 
Chalk and gum splints in fracture, 

349 
Chest, figure-of-eight bandage of, 
anterior, 70 

spiral bandage of, 70 

strapping of, 121 

T-bandage of, 31 
Chin, four-tailed bandage of, 32 
Chloride of ethyl, anaesthesia from, 
183 

of lime and sodium for sterilizing 
hands, 325 

of sodium, 307 

of zinc, 304 
Chloroform as a rubefacient, 134 

as a vesicant, 137 
Cholecystectomy, 602 
Cholecystenterostomy, 603 
Cholecystotomy, 601 
Choledochotomy, 602 



Chopart's amputation of foot, 517 
Chromic acid catgut, 312 
Chromicized catgut, 312 
Chronic abscess, treatment of, 260 
Circular bandage, 23 

enterorraphy, 618 
Circumcision, 599 
Clavicle, dislocation of, 422 
acromial end of, 423 
sternal end of, 423 

excision of, 544 

fracture of, 364 
in children, 369 
Clinical thermometer, 175 
Closed fracture, 341 
Clove-hitch knot, 419 
Coaptation sutures, 220 
Cocaine, 184 
Coccyx, dislocation of, 420 

excision of, 552 

fracture of, 362 
Cold, anaesthesia from, 183 

in arterial hemorrhage, 246 
Cold-water dressings, 131 
Colles's fracture of radius, 383 

reversed, 387 
Colon, operation on, 591 
Colostomy, inguinal, 592 

lumbar, 591 

Maydl's, 592 
Comminuted fracture, 341 
Common carotid arterv, ligation of, 

. . 457 
' iliac artery, ligation of, 469 

ligation of, transperitoneal, 

470 

Complete dislocation, 416 

fracture, 339 

Complicated dislocation, 416 

treatment of, 448 

fracture, 341 

Compound bandage, 27 

dislocation, 416 

treatment of, 448 

dorso-bis axillary cravat, 37 

fracture, 341, 410 

treatment of, 410 et seq. 

Compresses, 117 

in arterial hemorrhage, 240 

in fracture, 350 

Compression, 174 



636 



INDEX. 



Compression, digital, in arterial 
hemorrhage, 239 

in venous hemorrhage, 254 
Congenital dislocations, treatment 

of, 449 
Constriction, elastic, in arterial 

hemorrhage, 241 
Continued suture, 225 
Contused wounds, treatment of, 268 
Contusions, 271 
Coracoid process of scapula, fracture 

of, 370 
Coronoid of ulna, fracture of, 381 
Corrosive sublimate gauze, 316 
Costal cartilages, dislocation of, 421 \ 

fracture of, 360 
Cotton, 116 

absorbent, 116 

bichloride, 317 

gloves, 328 

sterilized, 318 
Counterirritation, 133 

Seguin's method, 137 
Crossed bandage of eye, 51 
Cumol catgut, 311 
Cupping, 141 

drv, 141 

wet. 142 
Cutting pliers, 488 
Cystoscope, 171 
Czerny suture, 233 

DECUBITUS, 277 
Deep incisions, 141 

sutures iti arterial hemor- 
rhage, 249 
Demi-gauntlet bandage, 56 
Desault's bandage, 65 
Diffuse suppuration, 262 
Digital compression in arterial 

hemorrhage, 239 
Dislocation or Dislocations, 416 
of acromial end of clavicle, 423 
of ankle, 444 
of carpal bones, 435 
of carpus, 435 
of clavicle, 422 
of coccyx, 420 
complete, 416 
complicated, 416 
treatment of, 448 



Dislocation, compound, 416 

treatment of, 448 
congenital, treatment of, 449 
of costal cartilages, 421 
of elbow, 431 
of femur, 437 

anomalous, 442 

backward, 437 

dorsal, 437 

downward, 439 

forward, 439 

and upward, 441 

pubic, 441 
of fibula, 444 
of fingers, 435 
habitual, 417 

treatment of, 449 
of head of humerus, 425 

of radius, 433 
of hip, 437 

of humerus, Koche'r's method in, 
429 

Mothe's method in, 429 

subclavicular, 425 

subcoracoid, 425 

subglenoid, 425 
of hyoid bone, 421 
of inferior angle of scapula, 424 
of knee, 443 
of lower jaw, 420 
of metacarpal bones, 435 
of metatarsal bones, 446 
old, 418,447 

reduction of, 447 
partial, 416 
of patella, 442 
pathological, 449 
of pelvis, 422 
of phalanges of fingers, 435 

of toes, 446 
recent, 4] 8 
of ribs, 421 
of scapula, 424 
of semilunar cartilages, 444 
of shoulder, 425 

reduction of, 426 et seq. 
simple, 416 

of sternal end of clavicle, 423 
of sternum, 422 
subspinous, of humerus, 426 
of tarsal bones, 445 



IXDEX. 



637 



Dislocation of toes, 446 

treatment of, 418 

of upper end of ulna, 433 

of vertebrae, 419 

of wrist, 434 
Dorsal dislocation of femur, 437 
Dorsalis pedis artery, ligation of,477 
Dorso-axillary cravat, 37 
Double ligature, 234 

roller-bandage, 20 

T-bandage, 30 
Drainage, catgut, 314 

horsehair, 314 
Drainage-tubes, 313 
Dressings, antiseptic, improvised, 
317 

aseptic, improvised, 317 

Bavarian, 105 

cold-water, 131 

fixed, 98 

gauze, 316 

moist method, 332 

plaster-of-Paris, 98 

provisional, in fracture, 345 

white lead, in burns, 272 

of wounds, 265 
Dry cupping, 141 

method of dressing wounds, 320 

sterilized gauze dressings, 318 
Dupuytren's amputation at shoul- 
der-joint, 507 

splint, 408 

ELASTIC constriction in arte- 
rial hemorrhage, 241 
ligature, 236 
gastroenterostomy with, 620 
Elastic- webbing bandage, 97 
Elbow, amputation at, 501 
dislocation of, 431 
figure-of-eight bandage of, 59 
Elbow-joint, excision of, 541 
Electricity, injuries from, 274 

treatment of, 275 
Electrolysis, 169 
Elimination of bacteria, 286 
Elliptical method in amputation, 

483 
Enema, glycerine, 161 

nutritious, 161 
Enemata, 160 



Enterectomy, 613 
Enterorraphy, circular, 618 
Enterotomy, 612 
Epiphyses, separation of, 351 
diagnosis of, 353 
prognosis of, 353 
symptoms of, 352 
treatment of, 354 
Epiphysis of humerus, upper, sepa- 
ration of, 372 
Epistaxis, treatment of, 255 
Erichsen's ligature, 236 
Esmarch's bandage, 243 
Estlander's operation on ribs, 545 
Ethyl chloride, anaesthesia from, 

183 
Excision or Excisions, 537 

of ankle-joint, 551 

of astragalus, 552 

of breast, 573 

of clavicle, 544 

of coccyx, 552 

of elbow-joint, 541 

of hip, anterior, 548 

of hip-joint, 547 

of interphalangeal joints, 544 

of joints, 537 

of knee-joint, 549 

of lower jaw, 554 

of mammary gland, 575 

of metacarpophalangeal joints, 
544 

of os calcis, 552 

of patella, 550 

of scapula, 546 

of shoulder-joint, 540 

of testicle, 600 

of upper jaw, 553 

of wrist-joint, 542 

Mynter's method, 543 
Exploring-needle, 165 
Extensor longus digitorum tendon, 
tenotomy of, 569 

proprius pollicis tendon, tenot 
omy of, 569 
External carotid arterv, ligation of, 
459 

iliac artery, ligation of, 471 

oesophagotorny, 603 

popliteal nerve, exposure of, 567 
Eye, crossed bandage of, 51 



638 



INDEX. 



FACIAL artery, ligation of, 461 
nerve, exposure of, 565 
Faradization, 170 
Feet, sterilization of, 322 
Felt splints, 114, 348 
Femoral artery, ligation of, 473 
hernia, radical cure of, 622 
truss for, 209 
Femur, dislocation of, 437 
anomalous, 442 
backward, 437 
dorsal, 437 
downward, 439 
forward and upward, 441 
iliac, 437 
pubic, 441 
thyroid, 439 
fracture of, 390 

ambulatory treatment in, 398 
incomplete, 397 
shaft of, 394 

in childreu, 397 
upper extremity of, 390 
osteotomy of, 556 
Fermenting poultice, 128 
Fibula, dislocations of, 444 
fracture of, 407 
Pott's fracture of, 407 
resection of, 551 
Figure-of-eight bandage, 26 
of chest, anterior, 70 

posterior, 71 
of elbow, 59 
of knee, 79, 81 
of leg, 85 

of neck and axilla, 63 
Fingers, amputation of, 494 
dislocation of, 435 
fractures of, 388 
spiral bandage of, 55 
Fissured fracture, 340 
Fixed dressings, 98 
Flannel bandage, 93 
Flat knot, 223 
Flaxseed poultice, 127 
Flexible catheters, 211 
Flexor longus pollicis tendon, ten- 
otomy of, 569 
Fluoroscope, 178 
Fly blister, 136 
Fomentations, hot, 128 



Foot, amputation of, 51], 514 

bandage of, American, 83 
French, 84 

spica bandage of, 81 
Forced respiration, 154 
Forceps, anastomosis, 619 

artery, 248 

bone, 488 

haemostatic, 243 
Forearm, amputation of, 500 

fracture of both bones of, 381 
Formaldehyde, 303 
Formalin, 303 

catgut, 311 
Four-tailed bandage of chin, 32 

of head, 32 
Fracture or Fractures, 339 

of acromion process of scapula, 
370 

anaesthetics in, 344 

bandage in, 349 

bed, 347 

of body of scapula, 390 

of bones of leg, 401 

ambulatory treatment in, 
406 

of both bones of forearm, 381 

box, 349 

of carpal bones, 388 

of clavicle, 364 et seq. 
in children, 369 
Sayre's dressing in, 366 
temporary dressing in, 365 
Velpeau's dressing in, 367 

closed, 341 

of coccyx, 362 

comminuted, 341 

complete, 339 

complicated, 341 

compound, 341, 410 

plaster-of- Paris dressing in, 412 
treatment of, 410 et seq. 

compresses in, 350 

of condyles of humerus, 375 

of coracoid process of scapula, 
370 

of coronoid process of ulna, 381 

of costal cartilages, 360 

cradle, 350 

deformity in, 343 

dressing of, 354 



INDEX. 



639 



Fracture, evaporating lotions in, 

350 
examination of, 343 
of femur, 390 

ambulatory treatment in. 398 

greenstick, 398 
of fibula, 407 
of lingers, 388 
fissured, 340 
greenstick, 339 

of ulna and radius, 383 
gunshot, 340 
of head of radius, 381 
of humerus, 370 
of hyoid bone, 359 
impacted, 341 
incomplete, 339 

of ulna and radius, 383 
indented, 340 

of inferior maxillary bone, 357 
of jaw, 356 
of larynx, 359 
longitudinal, 342 
of lower end of radius, 383 

extremity of humerus, 375 

jaw, 357 
of malar bone, 355 
massage in, 351 
of metacarpal bones, 388 
of metatarsal bones, 409 
multiple, 341 
of nasal bones, 354 
of neck of radius, 381 

of scapula, 370 
oblique, 341 

of olecranon process of ulna, 379 
open, 341, 410 
partial, 339 
of patella, 399 
of pelvis, 361 
perforating, 340 
of phalanges, 388 

of toes, 409 
plaster-of-Paris splints in, 349 
provisional dressings in, 345 
punctured, 340 
rack, 350 
reduction of, 346 
1 of ribs, 359 
of sacrum, 362 
of scapula, 369 



Fracture, setting of, 346 
of shaft of femur, 394 

in children, 397 
incomplete, 397 
of humerus, 373 
silicate of potassium splints in, 

349 
of sodium splints in, 349 
simple, 341 
of skull, 363 
splints in, 347 
starched splints in, 349 
of sternum, 360 
subperiosteal, 340 
of superior maxillary bone, 356 
symptoms of, 342 
of tarsal bones, 408 
of tibia and fibula, 401 
of trachea, 359 
transverse, 341 
of ulna and radius, 381 

incomplete, 383 
ununited, 414 
of upper extremity of femur, 390 

of humerus, 370 
varieties of, 339 
of vertebra?, 362 
x-ray examination in, 345 
of zygoma, 355 
Franklinization, 170 
Frontal sinus, trephining of, 561 

GALVAXO-CAUTERY, 169 
Gastro-duodenostomy, 611 
Gastroenterostomy, 612 
by elastic ligature, 620 
with Murphy button, 621 
Gastrostomy, 604 

Ssabanajew-F rank's, 605 
Witzel's, 607 
Gauntlet bandage, 55 
Gauze bandages, 90 
bichloride, 316 
carbolized, 317 
corrosive sublimate, 316 
dressings, 316 

dry sterilized, 318 
moist sterilized, 318 
pads, 308 
pledgets, 308 
sterilized, 318 



640 



INDEX. 



Gelatin in arterial hemorrhage, 246 
General anaesthesia, 183 
Gibson's bandage, 45 
Gloves, cotton, 328 

rubber, 327 

silk, 328 
Gluteal artery, ligation of, 472 
Gluteo-femoral triangle, 39 
Gluteo-inguinal cravat, 40 
Glycerin enema, 161 

tampon, 117 
Gonococcus, 290 
Granny knot, 223 
Greenstick fracture, 339 
of femur, 398 
of ulna and radius, 383 
Gritti's amputation at knee-joint, 

527 
Groin, spica bandage of, ascending, 
74 
descending, 76 
double, 77 

T-bandage of, 29 
Gunshot fracture, 340 

wounds, treatment of, 270 
Gunstock deformity in fracture of 

condyles of humerus, 376 
Gutta-percha splints, 348 

HABITUAL dislocation, 417 
Haemostatic forceps, 243 
Halsted's mattress suture, 232 
Hamstring tendons,tenotomy of, 569 
Hancock's amputation of foot, 521 
Hand or Hands, amputation of, 494 
removal of plaster of Paris from, 

108 
sterilization of, 324 

chloride of lime and sodium, 

325 
Harrington's method, 325 
by permanganate of potassium 
and oxalic acid, 325 
Handkerchief bandages, 33 

varieties of, 33, 34 
Hardening bandages, 98 
Hatter's felt splints, 114 
Head, bandages of, 42 
four-tailed bandage of, 32 
and neck bandage, 50 
oblique bandage of, 53 



Head, recurrent bandage of, 47 
transverse, 49 
V-bandage of, 49 
Heat, asepsis from, 299 
Hemorrhage, arterial, acupressure 
in, 251 

adrenalin chloride in, 246 

antipyrin in, 246 

cauterization in, 248 

compresses in, 240 

deep sutures in, 249 

digital compression in, 239 

elastic constriction in, 241 

gelatin in, 246 

hot water in, 246 

ligation in, 249 

permanent control of, 245 et seq. 

plaster tape in, 251 

position in, 245 

pressure in, 247 

styptics in, 246 

temporary control of, 239 et 
seq. 

torsion in, 248 

tourniquets in, 240 
capillary, treatment of, 254 
parenchymatous, treatment of, 

254 
from bladder, treatment of, 258 
from rectum, treatment of, 258 
from urethra, treatment of, 256 
secondary, treatment of, 254 
treatment of, 238 

constitutional, 238 

local, 238 
venous, actual cautery in, 253 

compression in, 254 

lateral ligature in, 253 

treatment of, 252 et seq . 
Hernia, femoral, radical cure of, 622 

truss for, 209 
inguinal, radical cure of, 624 

truss for, 208 
irreducible, truss for, 210 
strangulated, operation for, 621 
umbilical, radical cure of, 628 
Blake's method of, 628 

truss for, 210 
Hey's amputation of foot, 517 
Hilton's method in opening abscess, 
259 



INDEX. 



641 



Hip, dislocation of, 437 

Hip- joint, amputation at, 529 et seq. 

excision of, 547 
Horsehair drainage, 314 
Hot air, application of, 174 
fomentations, 128 
water in arterial hemorrhage, 246 
as rubefacient, 133 
Howard's method of artificial res- 
piration, 150 
Humerus, dislocation of head of, 
425 
epiphysis of, upper, separation of, 

372 
excision of, 540 
fracture of, 370 

of acromion process of, 370 
of condyles of, 375 

gunstock deformity in, 376 
Jones's method in, 377 
lower extremity of, 375 
shaft of, 373 
subclavicular dislocation of, 425 
subcoracoid dislocation of, 425 
subglenoid dislocation of, 425 
subspinous dislocation of, 426 
Hydrocele, operations for, 600 
Hydrogen peroxide, 305 
Hyoid bone, dislocation of, 421 

fracture of, 359 
Hypodermic injections, 162 

of mercury, 164 
Hypodermoclysis, 148 

TC&BAG, 132 

L Iliac arterv, common, ligation 
of, 469 
external, ligation of, 471 
internal, ligation of, 470 
ligation of, transperito- 
neal, 471 
dislocation of femur, 437 
Immediate irrigation, 129 
Immunity, 287 
Impacted fracture, 341 
Implantation of nerves, 563 
of ureter into bladder, 591 
Incised wounds, treatment of, 265 
Incisions, deep, 141 

in tuberculous abscess, 261 
Incomplete fracture, 339 
41 



Incomplete fracture of ulnar and 

radius, 383 
Indented fracture, 340 
Infected wounds, aseptic treatment 
of, 335 
antiseptic treatment of, 335 
Infection by bacteria, 286 
Inferior dental nerve, exposure of, 
564 
maxillary bone, excision of, 554 
thyroid artery, ligation of, 457 
Inflation, mouth to mouth, 150 
Infusion of saline solution, 148 
Inguinal colostomy, 592 
hernia, radical cure of, 624 
truss for, 208 
Injection of antitoxin, 163 
hypodermic, 162 
of mercury, hypodermic, 164 
in tuberculous abscess, 261 
urethral, 219 
Injuries from electricity, 274 
Innominate artery, ligation of, 453 
Inoculation by bacteria, 284 
Instruments for amputation, 486 

sterilization of, 326 
Internal carotid arterv, ligation of, 
460 
iliac artery, ligation of, 470 
mammary arterv, ligation of, 

457 
popliteal nerve, exposure of, 567 
pudic artery, ligation of, 472 
Interosseous artery, ligation of, 469 
Interphalangeal joints, excision of, 

544 
Interrupted plaster-of-Paris dress- 
ing, 102 
suture, 224 
Intestinal anastomosis, 614 
Abbe's method, 617 
end-to-end, Laplace, 619 
by forceps, 619 
bv Harrington's ring, 620 
lateral, 617 

by segmented ring, 620 
Senn's method, 616 
with Murphy button, 615 
sutures, 231 
Intestine, suture of, circular, 614 
Intoxication by bacteria, 286 .< 



642 



INDEX. 



Intravenous injection of saline solu- 
tion, 147 
Intubation of larynx, 582 et seq. 
Iodine catgut, 312 

as a rubefacient, 134 
Iodoform, 302 

collodion, 303 

emulsion, 303 

in tuberculous abscess, 261 

gauze, 316 
Irreducible hernia, truss for, 210 
Irrigation, 129 

of bladder, 218 

immediate, 129 

mediate, 130 
Isinglass plaster, 120 

JAW, lower, dislocation of, 420 
excision of, 554 
fracture of, 357 
oblique bandage of, 46 
upper, excision of, 553 
fracture of, 356 
Joints, excision of, 537 et seq. 

strapping of, 125 
Junk bags, 349 

KELENE, 183 
Kidney, operations on, 588 
Knee, dislocation of, 443 

figure-of-eight bandage of, 79, 81 
Knee-joint amputation at, 525 et 
seq. ' 

excision of, 549 

arthrectomy of, 549 
Knives, amputating, 486 
Knock-knee, osteotomy for, 556 
Knots for securing sutures and 

ligatures, 223 
Koch's law, 285 
Kocher's method in dislocations of 

humerus, 429 
Krause's method of skin-grafting, 

167 
Kreolin, 305 

LABOKDE'S method of artificial 
respiration, 154 
Lacerated wounds, treatment of, 

267 
Laminectomy, 561 



Larrey's amputation at shoulder- 
joint, 506 
Laryngo-tracheotomy, 582 
Laryngotomy, 581 
Larynx, fracture of, 359 

intubation of, 582 et seq. 
feeding after, 588 
operation of, 584 
Lateral ligature in venous hemor- 
rhage, 253 

lithotomy, 597 
Lavage, 158 

Leather splints, 112, 348 
Leech, mechanical, 144 
Leeching, 143 
Leg, amputation of, 521 et seq. 

figure-of-eight bandage of, 85 

fracture of bones of, 401 

ambulatory treatment in, 406 

spiral reversed bandage of, 84 
Lembert's suture, 231 
Lengthening of tendons, 572 
Liebreich's eye bandage, 88 
Ligation or Ligations,451 

of abdominal aorta, 469 

in arterial hemorrhage, 249 

of axillary artery, 462 

of brachial artery, 465 

of common carotid artery, 457 
iliac artery, 469 

of external carotid artery, 459 
iliac artery, 471 

of facial artery, 461 

of femoral artery, 473 

of gluteal artery, 472 

of inferior thyroid artery, 457 

of innominate artery, 453 

of internal carotid artery, 460 
iliac artery, 470 
mammary artery, 457 
pudic artery, 472 

of interosseous artery, 469 

of lingual artery, 460 

of occipital artery, 461 

of radial artery, 465 

of sciatic artery, 472 

of subclavian artery, 455 

of superior thyroid artery, 460 

of temporal artery, 461 

of ulnar artery, 467 

of vertebral artery, 456 



ISDEX. 



643 



Ligation of wounaea arteries. 252 
Ligatures in amputations, 49(J 

catgut. 310 

double, 234 

elastic, 236 

Erichsen's, 236 

lateral, 253 

quadruple, 235 

-touring of, 222 

silk, 309 

single, with pin, 234 

subcutaneous. 235 

in vascular growths, 233 
Lightning-stroke, 276 
Lingual artery, ligation of, 460 

nerve, exposure of. 564 
Lint, 115 

Lisfranc's amputation of foot, 
516 
of shoulder-joint, 508 
Lister's aorta compressor, 242 
Lithotomy, 597 

lateral, 597 

suprapubic, 598 
Local anesthesia, 182 
Longitudinal fracture, 342 
Lower extremity, bandasres of. 74 
spiral reversed bandage of, S4 

jaw. fracture of. 357 
Lumbar colostomy. 591 

nephrectomy, 588 

McBUEXEY'S hook-. 167 
operation in appendicitis, 
Mackintosh, 315 

Malar bone, fracture of. 355 
Malignant oedema, bacillu- of, 2V>2 
Mammarv artery, internal, ligation 
of, 4') 7 
gland, excision of. 573 
radical operation in, 574 
Many-tailed bandages, 31 

of abdomen, 32 
Massage, 173 

in fractures, 351 
Maxillarvbone, inferior, dislocation 
of, 420 
excision of, 554 
fracture of, 357 
superior, excision of, 553 
fracture of, 356 



Mechanical leech, 144 
Median nerve, exposure of, 566 
Mediate irrigation. 130 
Medio-tarsal amputation, 517 
Mento-vertico-occipital cravat, 35 

modified, 36 
Mercury bichloride, 300 

hypodermic injection of, 164 
Metacarpal bones, amputation of, 
497 
dislocation of, 435 
fracture of, 3SS 
resection of, 544. 552 
Metacarpophalangeal amputation, 
495 
joints, excision of, 544 
Metallic catheters, 211 
Metatarsal bones, amputation of, 
513 
dislocations of, 446 
fracture of. 409 
Mikulicz's amputation of foot, 521 
Modified circular amputation, 4S3 
Moist dressing in wounds, 320 

sterilized gauze dressings, 318 
Moulded plaster splint-. 107 

splints, 112 
Mouth, sterilization of. 324 
Mouth-to-mouth inflation. 150 
Multiple fracture. 341 
Murphy button. 615 

gastroenterostomy with, 621 
Muscle-graftincf, 169 
Musculo-spiral nerve, exposure of, 

566 
Muslin, oiled, 116 
Mustard papers, 135 
plaster, 134 
as a rubefacient. 134 

NV<AL bones, fracture of. 354 
cavities, sterilization of. 324 
Neck and axilla, figure-of-eight 

bandage of, 63 
Needle-holder, 222 

mounted. 222 

surgical. 221 
Xephrectomv, abdominal, 588 

lumbar, 588 
Nephropexy. 589 
ZSephrorrhaphy, 589 



644 



INDEX. 



Nephrotomy, 588 

Nerve or Nerves, anterior crural, 
exposure of, 567 

external popliteal, exposure of, 
567 

facial, exposure of, 565 

grafting, 169, 562 

implantation, 563 

inferior dental, exposure of, 564 

internal popliteal, exposure of, 
567 

lingual, exposure of, 564 

median, exposure of, 566 

musculo-spiral, exposure of, 566 

operations on, 562 et seq. 

popliteal, external, exposure of, 
567 
internal, exposure of, 567 

radial, exposure of, 566 

sciatic, exposure of, 566 

spinal accessory, exposure of, 
566 

stretching, 562 

superior maxillarv, exposure of, 
563 

supra-orbital, exposure of, 563 

suture of, 562 

ulnar, exposure of, 566 
Neurectasy, 562 
Neurectomy, 562 
Neuroplasty, 563 
Neurorrhaphy, 562 
Neurotomy, 562 
Nose, T-bandage of, 31 
Nutritious enema, 161 

Oakum, 115 
Oblique bandage, 23 
of head, 53 
of jaw, 46 
fracture, 341 
Occipital artery, ligation of, 461 
Occipitofacial bandage, 53 
Occipito-frontal bandage, 54 

triangle, 35 
(Esophageal bougie, 158 
CEsophagotomy, external, 603 
Oiled muslin, 116 

silk, 116 
Old dislocations, 418, 447 
reduction of, 447 



Olecranon process of ulna, fracture 

of, 379 
Open fracture, 341, 410 
Operating-bag, surgical, 319 
Operation or Operations, 451 

antiseptic, details of, 330 

for appendicitis, 593 

aseptic, clothing of surgeon for, 
328 
details of, 328 
material in, 308 et seq. 
preparation for, 321 
of patient for, 321 
of room for, 321 

on colon, 591 

for hernia, 621 et seq. 

for hydrocele, 600 

on kidney, 588 

on nerves, 562 

on stomach, 604 

on tendons, 567 

on ureter, 589 

for varicocele, 600 
Orthoform, 307 
Os calcis, excision of, 552 
Osteoplastic resection of skull, 559 
Osteotomy, 555 

for bowlegs, 556 

of femur, 556 

for knock-knee, 556 

of tibia, 556 
Oval method in amputation, 483 

PADS, gauze, 308 
Panelectroscope, 172 

Paper-lint, 115 
splints, 348 

Paquelin's thermo-cautery, 139 

Paraffin bandage, 112 
paper, 116 

Parchment-paper, 117 

Parenchymatous hemorrhage, treat- 
ment of, 254 

Partial dislocation, 416 
fracture, 339 

Passive motion, 173 

Pasteboard splints, 113 

Patella, dislocations of, 442 
excision of, 550 
fracture of, 399 

Pathogemc action of bacteria, 286 



INDEX. 



645 



Pathological dislocations, 449 
Pelvic supporter for application of 

plaster bandage, 101 
Pelvis, dislocation of, 422 

fracture of, 361 
Penis, spiral reversed bandage of, 

87 
Perforating fracture, 340 
Periosteal flaps in amputation, 486 
Periosteotome, 488 
Permanganate of potassium, 306 
Peroneal tendons, tenotomy of, 569 
Peroxide of hydrogen, 305 
Petit's tourniquet, 241 
Phalanges of lingers, dislocation of, 
435 
fracture of, 388 
of toes, dislocation of, 446 
fracture of, 409 
Picric acid dressing in burns, 273 
PirogofFs amputation at ankle-joint, 

519 
Plaster, adhesive, 118 
isinglass, 120 
mustard, 134 
resin, 119 

rubber adhesive, 119 
soap, 120 
swansdown, 119 

tape in arterial hemorrhage, 251 
zinc oxide, adhesive, 119 
Plaster-of-Paris bandage, applica- 
tion of, 100 
preparation of, 99 
renewal of, 109 
saw for, 110 
shears for, 110 
for thigh and pelvis, 101 
trapping of, 107 
dressings, 98 

application of, 98 
in compound fractures, 412 
interrupted, 102 
jacket, application of, 103 
removal of, from hands, 108 
splints in fracture, 349 
Plasters, 118 
Plate suture, 229 
Pledgets, gauze, 308 
Pliers, cutting, 488 
Poisoned wounds, treatment of, 269 



Popliteal artery, ligation of, 475 

nerve, exposure of, 567 
Position in arterial hemorrhage, 245 
Posterior figure-of-eight bandage of 
chest, 71 

tibial artery, ligation of, 477 
tendon, tenotomy of, 568 
Potassium permanganate, 306 

and oxalic acid for sterilizing 
the hands, 325 
Pott's fracture of fibula, 407 
Poultices, 126 

antiseptic, 128 

fermenting, 128 

flaxseed, 127 

soap, 127 

starch, 127 
Powder-burns. 271 

ress 

24: 

Pressure-sores, 277 
Primary suture of tendons, 570 
Protective, 314 

Pubic dislocation of femur, 441 
Pudic artery, internal, ligation of, 

472 
Puncturation, 141 
Punctured fracture, 340 

wounds, treatment of, 268 
Purse-string suture, 232 
Pylorectomy, 611 
Pyloroplasty, 607 

Finney's, 608 
Pyrozone, 305 



Q 



UADRUPLE ligature, 235 



RADIAL artery, ligation of, 465 
nerve, exposure of, 566 
Radius, Colles's fracture of, 383 
reversed, 387 
dislocation of head of, 433 
fracture of head of, 381 
lower end of, 383 
neck of, 381 
resection of, 541 
Rapid respiration, anaesthesia from, 

184 
Raw-hide splints, 112 
Ray fungus, 293 






IXDEX. 



Recent dislocation, 418 
160 
tube, 159 
Rectum, hemorrhage from, treat- 
men: : 258 
i 32-1 

Recurrent band - -' 
of head, 47 

tran- 
of stumi: . x ~ 
Redue:: ::ure, 346 

Reel knot 223 
Regional anaesthesia, 1 B 

ationsul - .- 
Removal :: sutures, 230 

dan or Resection-. r I ~ 
of fibula, 551 
of homer > '.- 
of metacarpal bones, 544. 5 52 
of radios, 541 
of ribs, 54-5 
f skull, osteoplastic, 559 
: : stern un, " - : 
: ::bia, 551 
of ulna. 541 
Resin plaster, 119 
Resistance ::' tissues to bacteria, 

ition, artificial. 149 
direct, 150 

Laborde's method, 154 
Silvester's method. 1 " . 
forced, 154 

rapid, anaesthesia from. 1 x i 
Retra:: r- 118 

in ampuu: : e 
Reverse ] ..'_-.---:'•. . acre : x ~ 
Ribs -. 421 

E -: Ian lei - n on, 545 

::.;■;-- 

resection of, 545 
Roller-bandage. 18 
Rontgenrav?. 177 

x s amputation at ankle-joint, 
_ z ... 

Rubber adhesive plaster, 119 
bandage, 94 
gloves 527 
tiss r. 117, 315 
sr-dam, 315 
Rubefacients, 133 



SACRUM, fractore or. - 
acid 306 

Sali:: . 

ana : 148 

intravenous injection of. 147 
Sand bags. 4 

.raputating 48 
for removal of pla?ter-of-Paris 
bandages, 110 
Scalds. 272 

Scalp, sterilization of, 324 
Scapula, dislocation o:. 424 
inferior angle : 424 
ex asi .... ~: : - 
fracture t : 

acromion proc se s 
body of, o70 
coracoid process of. 
neck of, - " 
Scarification. 141 
Sri Lie artery, ligation of, 4 - 

nerve, exposure 
Scopolamine hydrobromatc. . 
Scultetus ban hge, t 
Secondarv hemorrhage, treatment 
:". 254 
sutures. 2 _ 

of tendons. 591 
Sedillot" s amputation of leg. r I ' 
Segregation of urine, 216 
Seguin's method of counterirrita- 

tion. 137 
Semilunar cartilaffes, dislocation of, 

444 
3i ::-membranosos tendon, ten- 

otomj >1 
5* :>tendenosus tendon, tenotomv 

: "69 
Separation of epiphysis, 351 
Setting of fracture. -. 

for removal of plaster-of 
Paris bandaare. 110 
Shock, 262 
diagnosis ::'. 1 
prophykx:- : 264 
treamier:: :: ' '. 4 
Shor t 

Shoulder, dislocation of. -J.': 
red 
spica banc ge od lending, 60 
descending 



INDEX. 



64" 



Shoulder-joint, amputation at. 505 
above 
excision of, 540 

Signorini's tourniquet, 243 
Silicate of potassium bandage, 111 
splints in fracture, 34c* 
- diuru bandage. Ill 
splints in fracture, 349 
Silk glove,. 28 

ligatoi - 

oiled, 116 

sue. - 
Silkworm-gut, 309 
Silver foil. 315 

sale 
Silvesier's method of artineial res- 

piration, 152 
Simple dislocation, 4J 

fracture, 341 
Sinapism, 134 
Single ligature with pin, 234 

roller-bandage, 20 

T-bandage. 28 
Sinus, frontal, trephining of, 561 
Sinuses - - 
Skiagraphy. 177 
Skin-grafting. 165 

Krause"s method, 167 

Thiersch's method. 166 
Skull, fracture or. 

osteoplastic, resection of, 559 

trephining of, 557 
Slings. 31 

'.aster. 120 

poultice. 127 
Sodium chloride. 
Sounds. 213 
Spanish windlass. 241 
Spence's amputation at shoulder- 
join*. 
Spiea bandage. 26 

of buttock 

of foot. SI 

of groin, ascending. 74 
descending, 
double. 77 

of shoulder, ascending, 60 
descending 

Spinal accessor*- nerve, exposure of. 
566 



Spiral bandage, 23 
of chest, 1 . 

of finger, 55 
reversed bandage, 24 

of lower extremity. 54 
of penis. ^7 

of upper extremity. .; 8 
Splints, binders board, 113, 343 
chalk and gum in fracture, 349 
Dupuvtren s. 4u^ 
felt, 114. 348 
in fracture, 347 
gutta-percha, 348 
hatter's felt, 114 
leather, 112, 348 
moulded, 112 
papc- 

pasteboard, 113 
plaster, 1 

plaster-of-Paris, in fracture, 349 
raw-hide, 112 

silicate of potassium, in fracture, 
349 
of sodium in fracture, 349 
starched, 349 
V Ikmann's. 405 
wooden, 347 
Sponge-. 

- 2^2 
Sprain-fracture, 279 
strapping of. iT^ 



»prain' 



278 



Staffordshire knot. 223 
Staphylococcus pvogenes aureus, 
28 

Starch poultice. 127 

splints in fracture. 349 
Starched bandage. Ill 
Sterilization of bladder. 323 

of bougies. 21". . 

of catheters. 210. 326 

of feet. 322 

of hands. 324 

Harrington's method, 

of instruments. 326 

of mouth. 324 

of nasal cavities. 324 

of rectum. 324 
- :alp. 324 

of stomach. 323 

of urethra. 323 



325 



648 



INDEX. 



Sterilization of vagina, 323 
Sterilized bandages, 317 

catgut, 310 

water, 307 

cotton, 318 

gauze, 318 

dressings, moist, 318 
Sterno-cleido-rnastoid tendon, te- 
notomy of, 569 
Sternum, dislocation of, 422 

fracture of, 360 

resection of, 546 
Stomach, operation upon, 604 

sterilization of, 323 
Stomach-pump, 158 
Stomach-tube, 157 
Strains of fascia, 279 

of muscles, 279 
Strangulated hernia, operation for, 

621 
Strapping, 120 

the ankle-joint, 125 

the back, 126 

the chest, 121 

of joints, 125 

the testicle, 120 

of ulcere, 122 
Streptococcus pyogenes, 290 
Stump, recurrent bandage of, 87 
Stupe, turpentine, 134 
Stvptics in arterial hemorrhage, 

246 
Subastragaloid amputation of foot, 

518 
Subclavian arterv, ligation of, 

455 
Subclavicular dislocation of hu- 
merus, 425 
Subcoracoid dislocation of humerus, 

425 
Subcutaneous ligature, 235 
Subcuticular suture, 226 
Subglenoid dislocation of humerus, 

425 
Subperiosteal fracture, 340 
Subspinous dislocation of humerus, 

426 
Sulphocarbolate of zinc, 305 
Superior maxillary bone, excision 
of, 553 
nerve, exposure of, 563 



Superior thyroid artery, ligation 

of, 460 
Suppuration, bacteria of, 289 

diffuse, 262 
Supraorbital nerve, exposure of, 

563 
Suprapubic lithotomy, 598 
Surface thermometer, 177 
Surgeon's clothing for operations, 
328 

knot, 223 
Surgical bacteriology, 281 

needles, 221 

operating bag, 319 
Suspensory bandage of breast, 38 

and compressor bandage of 
breasts, 72, 73 
Suture or Sutures, 220 

in amputations, 490 

of approximation, 220 

in arterial hemorrhage, 249 

of arteries, 250 

buried, 225 

button, 229 

chain-stitch,226 

of coaptation, 220 

continued, 225 

Czernv, 233 

deep, 225 

interrupted, 224 

intestinal, 231 

of intestine, circular, 614 

Lembert's, 231 

mattress, Halsted's, 232 

of nerves, 562 

plate, 229 

purse string, 232 

of relaxation, 220 

removal of, 230 

secondary, 20 

securing of, 222 

shotted, 229 

silk, 309 

subcuticular, 226 

of tendons, 570 
primary, 570 
secondary, 571 

of veins, 253 
Swan's-down plaster, 119 
Syme's amputation of ankle-joint, 
*518 



INDEX. 



649 



TAMPON, 117 
glycerin, 117 
Tarsal bones, dislocation of, 445 

fracture of, 408 
Tarso-metatarsal amputations, 514 
T-bandage, 28 
of chest, 31 
double, 30 
of groin, 29 
of nose, 31 
single, 28 
Teale's amputation of leg, 524 

method in amputation, 484 
Temporal artery, ligation of, 461 
Tenaculum, 249 

Tendo Achillis, tenotomy of, 568 
Tendon, adductor longus, tenotomy 
of, 569 
anterior tibial, tenotomy of, 569 
biceps flexor cruris, tenotomy 

of, 569 
extensor longus digitorum, tenot- 
omy of, 569 
proprius pollicis, tenotomy of, 
569 
flexor longus pollicis, tenotomy 

of, 569 
hamstring, tenotomy of, 569 
lengthening of, 572 
operations on, 567 
peroneal, tenotomy of, 569 
posterior tibial, tenotomy of, 568 
semi-membranosus, tenotomy of, 

569 
semi-tendinosus, tenotomy of, 569 
sterno-cleido-mastoid, tenotomy 

of, 569 
suture of, 570 

primary, 570 
secondary, 571 
transplantation of, 573 
Tenotomy, 567 et seq. 
Tent, 117 
Testicle, excision of, 600 

strapping of, 120 
Tetanus, bacillus of, 292 
Thermometer, clinical, 175 

surface, 177 
Thiersch's method of skin-grafting, 

166 
Thigh, amputation of, 527 et seq. 



Thread, celluloid, 313 
Thumb, spica bandage of, 57 
Thyroid artery, superior, ligation 
of, 460 
inferior, ligation ef, 457 

dislocation of femur, 439 
Tibia and fibula, fracture of, 401 

osteotomy of, 556 

resection of, 551 
Toes, amputation of, 511 

dislocation of, 446 

fracture of phalanges of, 409 
j Torsion in arterial hemorrhage, 

248 
Tourniquets, 240 

in amputations, 490 

Petit's, 241 

Signorini's, 243 
Toxins, 287 

Trachea, fracture of, 359 
Tracheotomy, 575 et_ seq. 

high operation, 579 

operation of, 578 

tube, 577 
Transfixion method in amputations, 

482 
Transfusion, arterial, 147 

of blood, 146 
Transperitoneal ligation of common 

iliac artery, 470 
Transplantation of tendons, 573 
Transverse fracture, 341 

recurrent bandage of head, 49 
Trapping plaster-of-Paris bandage, 

107 
Trephining of antrum of Hislirnore, 
559 

frontal sinus, 561 

skull, 551 
Triangular cap of breast, 38 
Tripier's amputation of foot, 521 
Trunk, bandages of, 70 
Truss for femoral hernia, 209 

Hood's, 209 

for inguinal hernia, 208 

for umbilical hernia, 210 

worsted, 208 
Tubercle bacillus, 290 
Tuberculous abscess, incision in, 261 
injection in, 261 
puncture, 261 



650 



INDEX. 



Tuberculous abscess, treatment of, 

260 
Turpentine as rubefacient, 133 

stupe, 134 

ULCEUS, strapping of, 122 
Ulna, dislocation of upper end 
of, 433 
fracture of coronoid process 
of, 381 
of olecranon process of, 

379 
and radius, fracture of, 81 3 
resection of, 541 
Ulnar artery, ligation of, 467 

nerve, exposure of, 566 
Umbilical hernia, radical cure of, 
628 
truss for, 210 
Ununited fracture, 414 
Upper epiphysis of humerus, sepa- 
ration of, 372 
extremity, bandages of, 55 

spiral reversed bandage of, 58 
jaw, fracture of, 356 
Ureter, catheterization of, 216 
operations on, 589 
implantation of, in bladder, 591 
Ureterectomy, 589 
Ureterotomy, 589 
Uretero-ureterostomy, 590 
Urethra, hemorrhage from, treat- 
ment of, 256 
sterilization of, 323 
Urethral injections, 219 
Urethroscope, 172 
Urine, segregation of, 216 

TTACCINATION, 161 
V Vagina, sterilization of, 323 
Varicocele, operation for, 600 
Vascular growths, ligatures for, 233 
V-bandage of head, 49 
Veins, suture of, 253 
Velpeau's bandage, 63 
Venesection, 144 

Venous hemorrhage. See Hemor- 
rhage, venous. 
Vertebrae, dislocation of, 419 



Vertebrae, fracture of, 362 
Vertebral artery, ligation of, 456 
Vesicants, 136 
Volkmann's splint, 405 

WATEK, sterilized, 307 
Waxed paper, 116 
Wet cupping, 142 
White lead dressing in burns. 272 
Wood-wool, 116 
Wooden splints, 347 
Worsted truss, 208 
Wounded arteries, ligation of, 252 
Wounds, contused, treatment of, 
268 
dressings of, 265 

aseptic, 320 
dry method of dressing, 320 
drying and chemical sterilization 

in, 320 
gunshot, treatment of, 270 
incised, treatment of, 265 
infected, antiseptic treatment of, 
335 
aseptic treatment of, 335 
lacerated, treatment of, 267 
modified moist dressings in, 321 
moist dressing in, 320 
poisoned, treatment of, 269 
punctured, treatment of, 268 
redressing of, 333 
Wrist-joint, amputation at, 499 
dislocation of, 434 
excision of, 542 

Mynter's method, 543 
Wyeth's method of amputation at 
hip-joint, 532 
pins in amputation at shoulder- 
joint, 506 



X 



•rays, 177 
X-ray examination in fract- 
ure, 345 
burns, 276 



ZINC chloride, 304 
oxide adhesive plaster, 119 
sulphocarbolate, 305 
Zygoma, fracture of, 355 



